NU 272: Mobility
The nurse is caring for a client who sustained a femur fracture 3 days before. The nurse notes that the client, who was previously oriented, now doesn't know where he is. The nurse suspects which condition? Fat embolism syndrome (FES) Reflex sympathetic dystrophy Compartment syndrome Osteomyelitis
Fat embolism syndrome (FES) The FES refers to multiple life-threatening manifestations from the presence of fat droplets in the small blood vessels of the lung, kidney, brain, and other organs after a long bone (femur) or pelvic fracture. Initial symptoms of FES begin to develop within a few hours to 3 to 4 days after injury. The first symptoms include subtle changes in behavior and signs of disorientation. Reflex sympathetic dystrophy represents soft tissue complications of musculoskeletal injuries. Compartment syndrome is a condition of increased pressure within a limited space. Osteomyelitis represents an acute or chronic infection of the bone.
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: Complex regional pain sydrome Delayed union Compartment syndrome Fat embolism syndrome
Fat embolism syndrome The clinical manifestations described in the scenarion are characteristic of fat embolism syndrome.
Which clinical finding would the nurse expect when caring for a client who has thrombophlebitis of the left lower leg? Edema of the left calf Weakness of the left foot Positive left-sided Babinski reflex Absence of left dorsalis pedis pulse
Edema of the left calf Swelling of the extremity is indicative of thrombophlebitis because inflammation of the vein impairs venous return. Weakness of the extremity might occur with a decrease in arterial blood flow or with musculoskeletal or neuromuscular problems. Positive left-sided Babinski reflex is associated with neurological deficits in the corticospinal tracts. Absent or decreased pulses occur with decreases in arterial blood flow.
An older adult client has been prescribed an anticholinergic agent for treatment of Parkinson-related symptoms. What client education should be provided by the nurse? "Avoid high environmental temperatures." "Anticholinergics increase mental alertness." "It is safe to take pseudoephedrine for a cold." "You may experience urinary incontinence."
"Avoid high environmental temperatures." Anticholinergic drugs decrease sweating and may cause heat stroke. The client should be instructed to avoid high environmental temperatures. Anticholinergic agents will decrease mental alertness. Pseudoephedrine will produce anticholinergic effects and should not be administered. Anticholinergic agents produce urinary retention, not incontinence.
A male client is prescribed levodopa for his Parkinson's disease. The dosage has been modified on multiple occasions. The client asks the nurse how the prescriber decides on the optimal dose. What is the nurse's best response? "The optimal dose is the highest one that allows the client to function adequately." "The optimal dose is the one that allows the client to function adequately." "The optimal dose is the lowest one that allows the client to function adequately." "The optimal dose is the one that maximizes client function."
"The optimal dose is the lowest one that allows the client to function adequately." The optimal dose is the lowest one that allows the client to function adequately. Optimal dosage may not be established for 6 to 8 weeks with levodopa.
When a nurse is assessing a client with osteoarthritis, which assessment findings does the nurse consider consistent with this disorder? Select all that apply. Aching diffuse pain in the involved area Grinding sensation palpated upon movement Size of joint small and "mushy" Pain relieved by movement Limited range of motion
Aching diffuse pain in the involved area Grinding sensation palpated upon movement Limited range of motion Initially, pain may be described as aching and may be somewhat difficult to localize. It usually worsens with use or activity and is relieved by rest. Joint enlargement usually results from new bone formation; the joint feels hard, compared to the spongy joint of rheumatoid arthritis. Limited range of motion may be present.
A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect? Infection Pulmonary embolism Avascular necrosis Hypovolemic shock
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.
At which of the following spinal cord injury levels does the patient have full head and neck control? C5 C4 C3 C2
C5 At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.
Which findings would be present in a client who has fat embolism syndrome? Select all that apply. One, some, or all responses may be correct. Decreased PaO2 Increased platelet count Lipids in the urine Decreased hematocrit level Decreased prothrombin time
Decreased PaO2 Lipids in the urine Decreased hematocrit level The diagnostic abnormalities present in a client with fat embolism syndrome are decreased PaO2, increased fat cells in urine, decreased hematocrit level, decreased platelet count, and prolonged prothrombin time.
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered Placing the client in Trendelenburg's position Monitoring the patency of an indwelling urinary catheter
Monitoring the patency of an indwelling urinary catheter A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.
A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for? Rebound hypotension Rebound hypertension Urinary tract infection Spinal shock
Rebound hypotension When the cause is removed and the symptoms abate, the blood pressure goes down. The antihyperstensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before.
Entacapone has been recently added to the medication regimen of a client with Parkinson's disease. The nurse should recognize what likely rationale for this change in medication regimen? The client's Sinemet was likely less effective than in the past The client likely developed worsening adverse effects of Sinemet The client likely developed a comorbidity that contraindicated the use of levodopa The client was likely unable to adhere to the strict dosing schedule of other medications
The client's Sinemet was likely less effective than in the past Entacapone is an adjunctive agent used to treat Parkinson's disease. It is used with levodopa-carbidopa for clients who are experiencing "wearing off" of drug effects.
The nurse is caring for a client who has quadriparesis from a spinal cord injury. Which rationale explains why fluid intake would be increased for this client? To prevent dehydration To maintain electrolyte balance To prevent a urinary tract infection To limit an increase in temperature
To prevent a urinary tract infection Patients with quadriparesis has reduced movement which leads to urinary stasis and as a result UTIs and calculus formation. All individuals require fluid to prevent dehydration; this is not why fluids are encouraged for this client. Administration of fluids does not maintain electrolyte balance. Fluids do not prevent an increase in temperature.
Indications for use of anticholinergic drugs in the treatment for Parkinsonism include to: decrease headaches. improve blurred vision. decrease salivation, spasticity, and tremors. decrease motor movement.
decrease salivation, spasticity, and tremors. Anticholinergic drugs are used in idiopathic parkinsonism to decrease salivation, spasticity, and tremors. They are used primarily in people who have minimal symptoms or who cannot tolerate levodopa, or in combination with other antiparkinson drugs.
A nurse is educating a client who has Parkinson's disease and family regarding possible adverse effects of carbidopa-levodopa. The nurse emphasizes which should be a closely monitored effect? involuntary movements. perspiration. appetite or thirst. mobility.
involuntary movements Abnormal and involuntary movements are among the most common and serious adverse effects of carbidopa-levodopa therapy. Increased appetite, thirst, and perspiration are not common adverse effects, and increased mobility is a desired outcome of treatment.
A client has been diagnosed with Parkinson's disease and the primary health care provider has prescribed levodopa(100 mg)-carbidopa(10 mg) PO q8h. What is the nurse's best action? Administer the medication as prescribed and monitor for therapeutic and adverse effects Contact the provider to question the frequency Contact the provider to question the dose Contact the provider to question the route
Administer the medication as prescribed and monitor for therapeutic and adverse effects This prescription is within recommended parameters. The nurse should administer the medication and monitor the client.
Which of the following is the earliest sign of increasing intracranial pressure (ICP)? Change in level of consciousness (LOC) Seizures Restlessness Pupil changes
Change in level of consciousness (LOC) The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately. Seizures, restlessness, and pupil changes may occur, but these are not the earliest signs.
A female client is prescribed centrally acting anticholinergics for her Parkinson's disease. Six weeks later, her daughter asks the health care provider to hospitalize the client for a psychiatric evaluation. The nurse anticipates that the provider will respond in what way to the daughter's request? Evaluate the client for adverse reactions from the centrally acting anticholinergics Increase the centrally active anticholinergics to decrease the client's symptoms Admit the client to the hospital for a psychological evaluation Immediately discontinue the centrally acting anticholinergic medication
Evaluate the client for adverse reactions from the centrally acting anticholinergics When centrally active anticholinergics are given for Parkinson's disease, agitation, mental confusion, hallucinations, and psychosis may occur.
A hemodynamically stable and conscious client is brought into the emergency department after a crush injury to the pelvis from all-terrain vehicle (ATV) rollover. What action should the nurse prioritize? Inserting an intravenous catheter Assessing blood pressure and heart rate Gaining a detailed history of the incident Preventing movement of the pelvic area
Preventing movement of the pelvic area The nurse should be concerned about the risk for fat emboli syndrome (FES) due to pelvic fracture. The only preventive approach to FES is early stabilization of the fracture; therefore, the nurse should ensure that the pelvic area is kept as immobile as possible while performing other actions such as gaining IV access, gathering a history, and assessing vital signs.
Which would a nurse identify as least likely to contribute to a decrease in the effectiveness of levodopa? Pyridoxine Phenytoin Multivitamin supplement St. John's wort
St. John's wort St. John's wort can lead to hypertensive crisis if taken with rasagiline, not levodopa. Decreased effectiveness of levodopa is seen with the use of pyridoxine (vitamin B6), phenytoin, and multivitamin supplements.
A client's dose of Sinemet has recently been increased due to an exacerbation of the client's parkinsonian symptoms. What assessment finding would suggest that the client is experiencing adverse effects? The client is retaining urine and has required a urinary catheter The client's blood pressure is 152/93 mm Hg and the client has no history of hypertension The client is diaphoretic despite being afebrile The client has had diarrhea twice in the past two days
The client is retaining urine and has required a urinary catheter Adverse effects of levodopa include urinary retention. Diarrhea, increased blood pressure and diaphoresis would likely be attributable to other factors.
A teenager is being discharged with a cast. Which would the nurse recommend if the client experiences pruritus around the cast edges? "Scratch the itchy area gently." "Put an ice pack on the affected area." "Sprinkle a layer of powder around the itchy spots." "Ask your doctor for a prescription for an antihistamine."
"Put an ice pack on the affected area." An ice pack numbs the area and may temporarily diminish the discomfort. Scratching stimulates the release of histamine, which worsens the pruritus; also, scratching may break the skin and open an avenue for infection. Powder may become caked and slip under the cast, causing additional discomfort. Also, powder should be avoided because it is toxic if inhaled. Antihistamines are not prescribed unless all other measures have failed.
Which action would be most important postoperatively for a client who has had a knee or hip replacement? Providing crutches to the client. Assisting in early ambulation. Using a continuous passive motion (CPM) machine. Encouraging expressions of anxiety.
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 nurse is teaching a class about osteoporosis. Which factors place a client at greater risk for developing this disease? Select all that apply. postmenopausal status long-term use of corticosteroids long-term use of ibuprofen excessive intake of calcium supplements early onset of menses sedentary lifestyle
postmenopausal status long-term use of corticosteroids sedentary lifestyle The greatest incidence of osteoporosis occurs between ages 50 and 70 years. Risk factors include postmenopausal status, long-term use of corticosteroids, immobility and lack of exercise, and calcium deficiency. Long-term ibuprofen use and early onset of menses are not considered risk factors for osteoporosis.
What would be considered a peripheral anticholinergic effect of anticholinergic drug therapy? Delirium Blurred vision Agitation Memory loss
Blurred vision Blurred vision is considered a peripheral anticholinergic effect. Delirium, agitation, and memory loss are considered central effects affecting the CNS.
A client who has experienced a spinal cord injury has an ipsilateral loss of voluntary motor function and a contralateral loss of pain and temperature sensation. Based on these symptoms, which classification of spinal cord injury does the client have? Paraplegia Tetraplegia Anterior Cord Syndrome Brown Sequard
Brown Sequard Explanation: A condition called Brown-Séquard syndrome results from damage to a hemisection of the anterior and posterior cord. The effect is an ipsilateral loss of voluntary motor function from the corticospinal tract and proprioception loss with a contralateral loss of pain and temperature sensation from the lateral spinothalamic tracts for all levels below the lesion.
A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the: Midbrain. Cerebellum. Pons. Medulla oblongata.
Cerebellum. The cerebellum is largely responsible for coordination of all movement. It also controls fine movement, balance, position (postural) sense or proprioception (awareness of where each part of the body is), and integration of sensory input.
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? Chest strapping Mechanical ventilation Coughing and deep breathing with pillow splinting Thoracentesis
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.
Which equipment would the nurse recommend to foster independence at home for an ambulatory client who has Parkinson disease? A raised toilet seat Side rails for the bed Crutches for ambulation A trapeze above the bed
A raised toilet seat A raised toilet seat will make it easier for the patient to use because of the shorter distance to sit down. Parkinson's patients are not bedridden and do not need side rails or a trapeze for the bed. Because of bradykinesia, stiffness, and slowness, crutches will be dangerous.
When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor? Signs of infection Intake and output Nutritional status Body temperature
Body temperature It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.
After teaching a class about the different drugs used to treat Parkinson disease, the instructor determines that the teaching was successful when the class identifies which enzyme as responsible for the elimination of dopamine and prolongs the effect of levodopa? Catechol-O-methyltransferase Acetylcholinesterase Tyrosine hydroxylase Cholminesterase
Catechol-O-methyltransferase Catechol-O-methyltransferase is the enzyme responsible for the breakdown of dopamine and its inhibitor is used as a target in the therapy for parkinsonism. Acetylcholinesterase also called cholinesterase breaks down acetylcholine and stops the signal between a nerve cell and a muscle cell. Tyrosine hydroxylase (TH) is a critical enzyme in normal dopamine production
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 hip more than 30 degrees. Do not flex the hip more than 60 degrees. Do not flex the hip more than 90 degrees. Do not flex the hip more than 120 degrees.
Do not flex the hip 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 fracture.
A nurse is reviewing a client's history for conditions that would contraindicate the use of anticholinergics for Parkinson's disease. Which would cause the nurse to be concerned? Hypertension Myasthenia gravis Hepatic dysfunction Cardiac arrhythmia
Myasthenia gravis Anticholinergics are contraindicated for clients with myasthenia gravis, which could be exacerbated by the blocking of acetylcholine receptor sites at the neuromuscular synapses. Hypertension, hepatic dysfunction, and cardiac arrhythmia would require cautious use.
A client sustains an injury to the ligaments surrounding a joint. What will the nurse identify this injury as? Strain Contusion Sprain Fracture
Sprain A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.
A health care provider has asked the nurse to educate a client with Parkinson disease regarding the client's medication regimen. Because the client is taking carbidopa-levodopa, the nurse will assess the client's existing medication regimen for: beta-blockers. potassium-wasting diuretics. NSAIDs. tricyclic antidepressants.
tricyclic antidepressants. Carbidopa-levodopa can interact substantially with hydantoins, MAOIs, phenothiazines, or tricyclic antidepressants. It does not interact appreciably with NSAIDs, diuretics, or beta-blockers.
The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? Occipital skull fracture Temporal skull fracture Frontal skull fracture Basilar skull fracture
Basilar skull fracture A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).
Clients taking levodopa should avoid what due to their ability to increase dopa decarboxylase action? Lima beans, navy beans, and certain cereals Supplemental vitamins Foods high in polyunsaturated fats Foods with a high sodium content
Supplemental vitamins Levodopa is well absorbed from the small intestine after oral administration, reaches peak serum levels within 30 to 90 minutes, and has a short serum half-life (1-3 hours). Absorption is decreased by delayed gastric emptying, hyperacidity of gastric secretions, and competition with amino acids (from digestion of protein foods) for sites of absorption in the small intestine. Pyridoxine (vitamin B6) promotes the breakdown of levodopa, reducing its effectiveness.
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 affected hip flexed acutely With the leg on the affected side abducted With the leg on the affected side adducted With the affected hip rotated externally
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.
The home care nurse is caring for an 80-year-old patient who is receiving carbidopa-levodopa, a dopaminergic drug used to treat Parkinson's disease. The nurse knows that this drug may place the patient at increased risk for: infection. falls. excessive sedation. uncontrolled bleeding.
falls. Adverse effects of dopaminergic drugs such as carbidopa-levodopa include orthostatic hypotension. The dizziness and potential for fainting associated with this effect can increase the risk of falls.
The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a client who has sustained a fracture. The nurse suspects which complication? Compartment syndrome Hypovolemic shock Fat embolism syndrome Reflex sympathetic dystrophy syndrome
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.
Which client is most likely to experience complications in bone healing due to avascular necrosis? Older adult with an intertrochanteric fracture of the hip Middle-aged adult with a stress fracture of the tibia Young adult with compound fracture of the humerus Child with a greenstick fracture of the radius
Older adult with an intertrochanteric fracture of the hip Subtrochanteric and intertrochanteric fractures that occur distal to these vessels do not usually disturb the blood supply to the femoral head, whereas femoral neck fractures, particularly those involving marked displacement, often disrupt the blood supply to the femoral head and are therefore associated with increased incidence of complications (nonunion and avascular necrosis). Fractures that involve an open wound are most prone to nonunion, infection, or osteomyelitis. Closed fractures generally heal more quickly and with fewer complications.
The nurse is caring for a client who sustained a femur fracture 3 days before. The nurse notes that the client, who was previously oriented, now doesn't know where he is. The nurse suspects which condition? Fat embolism syndrome (FES) Reflex sympathetic dystrophy Compartment syndrome Osteomyelitis
Fat embolism syndrome (FES) The FES refers to multiple life-threatening manifestations from the presence of fat droplets in the small blood vessels of the lung, kidney, brain, and other organs after a long bone (femur) or pelvic fracture. Initial symptoms of FES begin to develop within a few hours to 3 to 4 days after injury. The first symptoms include subtle changes in behavior and signs of disorientation. Reflex sympathetic dystrophy represents soft tissue complications of musculoskeletal injuries. Compartment syndrome is a condition of increased pressure within a limited space. Osteomyelitis represents an acute or chronic infection of the bone. Reference:
Which action can the nurse take to ensure that Buck's traction is being applied correctly? Fit the spreader bar snugly around the client's foot. Position the boot so it extends 3 inches (7.6 cm) above the client's ankle. Hang the weight to apply traction, but limit it to 10 lb (4.5 kg). Cover the malleoli with tape to secure the weights to the leg.
Hang the weight to apply traction, but limit it to 10 lb (4.5 kg). Eight pounds of weight commonly is applied to maintain adequate traction. Weight greater than 5 to 10 lb (2.3-4.5 kg) causes excessive tension on the skin, leading to damage. The spreader bar should be wide enough to keep materials away from the malleoli. The Buck boot should extend to the area just below the knee. Tape is unnecessary when a Buck boot is used.
A client with a complex medical history has been diagnosed with Parkinson's disease and prescribed carbidopa-levodopa. What aspect of this client's health status should most prompt the nurse to monitor the client closely? The client had a myocardial infarction ten months ago The client takes levothyroxine for the treatment of hypothyroidism The client has rheumatoid arthritis and takes celecoxib The client is obese, with a body mass index of 32.5
The client had a myocardial infarction ten months ago Recent cardiovascular disease necessitates cautious use of dopaminergics. Obesity, NSAID use, inflammatory conditions, use of thyroid supplements and hypothyroidism are not reported to require cautious use and do not contraindicate the use of dopaminergics.
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 Proper use of a sling Repositioning the arm in the cast Abduction and adduction of the shoulder
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.
A client has undergone a leg amputation. What teachings should the nurse offer such a client to prevent abduction deformity? Select all that apply. Advise the client to use a trochanter roll. Advise the client to adduct the stump so it presses against the other leg when the client is lying on the stomach. Advise the client to use antiembolism stockings on both legs. Advise the client to place pillows between the legs.
Advise the client to use a trochanter roll. Advise the client to adduct the stump so it presses against the other leg when the client is lying on the stomach. Use a trochanter roll to prevent external rotation of the hip and knee. Avoid placing pillows between the legs. If the client is lying on the stomach, the nurse should advise the client to adduct the stump so it presses against the other leg. Adduction stretches flexor muscles and prevents abduction deformity. The client should only use an antiembolism stocking on the unaffected leg.
A client who sustained a complete C6 spinal cord injury 6 months ago has been admitted to the hospital for pneumonia. The nurse observes the client with diaphoresis above the level of C6 and the blood pressure is 260/140 mm Hg. What is the first intervention the nurse should provide? Elevate the head of the bed. Disimpact the stool from the anal vault. Insert an indwelling catheter. Give the client some orange juice and sugar.
Elevate the head of the bed. Autonomic dysreflexia is a clinical emergency, and without prompt and adequate treatment, convulsions, loss of consciousness, and even death can occur. The major components of treatment include monitoring blood pressure while removing or correcting the initiating cause or stimulus. The person should be placed in an upright position, and all support hose or binders should be removed to promote venous pooling of blood and reduce venous return.
The nurse is providing client education related to intra-articular corticosteroid injections. Which instruction should the nurse include? The injections will be given only 3 to 4 times per year because they can increase joint destruction. There will be minimal discomfort because the injections are placed in the subcutaneous tissue. The client or a family member will be taught to administer the injections daily. There will be immediate relief with one injection and daily running can be resumed.
The injections will be given only 3 to 4 times per year because they can increase joint destruction. The client needs to be educated regarding the limited use of the injections and the risk of these injections causing additional joint destruction. The client should not be encouraged to run, but can participate in muscle-strengthening exercises. The statements regarding discomfort and daily administration are not correct.
The client with osteoporosis asks the nurse to explain what a bisphosphonate medication does. The nurse will respond: This medication helps prevent bone resorption, which in turn will help prevent fractures. These drugs increase your phosphorus levels and thereby help with your calcium levels as well. This medication stimulates your parathyroid gland to increase osteoclastic activity. This medication plays an important role in bone remodeling.
This medication helps prevent bone resorption, which in turn will help prevent fractures. Bisphosphonates are effective inhibitors of bone resorption and the most effective agents for the prevention and treatment of osteoporosis. The bisphosphonates bind to hydroxyapatite and prevent bone resorption by inhibiting osteoclast activity. They are effective in reducing the risk of hip, vertebral, and nonvertebral fractures.
Which priority nursing intervention would the nurse include in the plan of care for an older adult who sustained a right hip fracture? Oxygen therapy Cardiac monitoring Nutrition supplements Venous thromboembolism (VTE) prevention
Venous thromboembolism (VTE) prevention After hip surgery, development of a VTE commonly occurs. Nursing must implement preventive intervention; this is a component of core measures. Nutritional supplements, cardiac monitoring, and oxygen therapy may be necessary in some clients with hip fractures, but not in all.
A client diagnosed with Parkinson's disease has been prescribed rasagiline. When educating this client on this medication, which herbal supplement should be identified as having the potential to produce hyperpyrexia and death? ginger dextromethorphan garlic St. John's wort
St. John's wort Rasagiline administered with the herbal supplement St. John's wort will enhance the stimulation of serotonergic receptors to cause hyperpyrexia and death. Dextromethorphan can produce the same reaction but is not an herbal supplement. Ginger and garlic are herbal supplements but will not produce hyperpyrexia and death.
Common side effects of anticholinergics include: dry mouth, urinary retention, constipation, and increased pulse rate. blurred vision, decreased liver enzymes, increased B/P, and papillary constriction. decreased GI absorption, nausea, heartburn, and hypotension. skin rashes, decreased urinary output, constipation, and increased WBCs.
dry mouth, urinary retention, constipation, and increased pulse rate. Anticholinergic drugs may cause blurred vision, dry mouth, tachycardia, and urinary retention. They also decrease sweating and may cause fever or heatstroke. Fever may occur in any age group, but heatstroke is more likely to occur in older adults, especially with cardiovascular disease, strenuous activity, and high environmental temperatures. When centrally active anticholinergics are given for Parkinson's disease, agitation, mental confusion, hallucinations, and psychosis may occur.
A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? Performing passive range-of-motion (ROM) exercises on the client's legs once each shift Keeping a pillow between the client's legs at all times Turning the client from side to side every 2 hours Maintaining the client in semi-Fowler's position
Keeping a pillow between the client's legs at all times After open reduction with internal fixation, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period, because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After open reduction with internal fixation, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.
A client with a closed reduction of a wrist fracture has a plaster cast applied. Which nursing intervention is the highest priorityimmediately after the procedure? Elevating the extremity on a pillow Performing a peripheral circulation assessment Immobilizing the arm in a sling Handling the cast with the palms of the hands
Performing a peripheral circulation assessment Complications of fractures include compartment syndrome (when swelling after the injury impairs blood and nerve function), delayed healing, infection, and emboli. Of these conditions, compartment syndrome has the earliest onset and is monitored by peripheral circulation assessment. This includes capillary refill, temperature of the distal extremity, and sensation and the ability to move fingertips.
The nursing student is studying hip fractures. The faculty member knows that the student understands the topic when she states: "Risk factors for hip fracture include high body mass index (BMI) and tall body structure." "Femoral neck fractures, with marked displacement, are associated with an increased incidence of avascular necrosis." "Subtrochanteric fractures account for the majority of hip fractures." "MRIs are required to diagnose hip fractures."
"Femoral neck fractures, with marked displacement, are associated with an increased incidence of avascular necrosis." Femoral neck fractures, particularly those involving marked displacement, often disrupt the blood supply to the femoral head and are therefore associated with an increased incidence of complications (nonunion and avascular necrosis). Risk factors for hip fracture include low body mass index (BMI) and tall body structure. Femoral neck and intertrochanteric fractures account for the majority of hip fractures. Most hip fractures are diagnosed based on clinical findings and standard radiographs. A bone scan for MRI may be done when radiograph is negative but the clinical findings support the diagnosis of hip fracture.
A 64-year-old man was diagnosed 19 months ago with bilateral osteoarthritis (OA) in his knees, and has come to his family physician for a checkup. The client and his physician are discussing the effects of his health problem and the measures that the man has taken to accommodate and treat his OA in his daily routines. Which statement by the client would necessitate further teaching? "I'm really trying to lose weight and I've been able to lose 15 pounds this year so far." "I've been doing muscle strengthening exercises twice a week at the community center near my house." "Even though I don't like it, I've been using my walker to take some of the weight off my knees." "I've been avoiding painkillers because I know they can mask damage that I might be inflicting on my knees."
"I've been avoiding painkillers because I know they can mask damage that I might be inflicting on my knees." Analgesics are a common and appropriate treatment for OA, and it would be unnecessary and inappropriate to forego pain control in order to maximize pain signals from affected joints. Weight loss, the use of assistive devices, and muscle-strengthening exercises are appropriate treatments for OA.
After seeking care for tremors that have become increasingly severe in recent months, a 71-year-old man has been diagnosed with Parkinson's disease and will soon begin treatment with carbidopa-levodopa. Which statement indicates that the patient has an accurate understanding of the new medication? "I'll have to learn how to modify each dose of carbidopa-levodopa based on how bad my symptoms are that day." "I've read that carbidopa-levodopa is quite short-acting so I'll have to take it several times a day." "I'll make sure to stop taking my other medications so that my carbidopa-levodopa doesn't interact with them." "I've heard that it can take up to a year for carbidopa-levodopa to cure someone of Parkinson disease."
"I've read that carbidopa-levodopa is quite short-acting so I'll have to take it several times a day." The plasma half-life of both carbidopa-levodopa and carbidopa alone is roughly 1 to 2 hours, and the duration of action of a dose is 5 hours. Consequently, most patients must take the drug several times daily. Carbidopa-levodopa does not cure Parkinson's disease and individual doses are not normally based on the short-term severity of symptoms. The patient's existing medications must be assessed, but complete cessation of all drugs is not necessarily required.
A nurse is educating a patient newly diagnosed with Parkinson's disease. Which description would the nurse offer to describe the disease? "It is an acute disorder." "It is characterized by abnormalities in behavior." "It is characterized abnormalities in posture." "It is characterized by joint pliancy."
"It is characterized abnormalities in posture." Parkinson's disease is a chronic, progressive, degenerative disorder of the central nervous system characterized by abnormalities in movement and posture (e.g., tremor, bradykinesia, joint and muscular rigidity, postural instability).
The nurse is caring for an 8-year-old child in traction. The client has been in an acute care setting for 2 weeks and will require an additional 10 days in the hospital. The client is showing signs of regression with thumb sucking and pleas for the now tattered baby blanket. What would be the most helpful intervention? "Let's ask your parents to bring your friends for a visit." "Would you like a coloring book?" "You are too big to suck your thumb." "Do you want a book to read?"
"Let's ask your parents to bring your friends for a visit." After 2 weeks in traction, a child can become easily bored and regress in social and personal skills. A visit from friends arranged by the child's parent or supervised by the child-life specialist would help the client adapt to the immobilized state. Telling the clinet that he or she is too big to suck the thumb is unhelpful. Suggesting a book or coloring book would be unhelpful at this point, as the child has likely grown tired of books and coloring after 2 weeks.
A client has a shoulder immobilizer after surgical repair of a fractured humerus. Which instruction would the nurse provide to the client about the correct use of the immobilizer? "Place the elbow on a pillow when sitting in a chair." "Adjust the upper arm and wristbands so they are slack." "Loosen the chest band to exercise the shoulder periodically." "Release the wristband to exercise the forearm and hand routinely."
"Release the wristband to exercise the forearm and hand routinely." Wrist flexion and extension, and forearm pronation and supination while the elbow is maintained against the chest, constitute part of a prescribed exercise program after this surgery; this promotes circulation and prevents musculoskeletal stiffness. Placing the elbow on a pillow when sitting in a chair will create pressure within the shoulder joint and will disturb healing. The shoulder immobilizer and its two bands should fit snugly but at no time should constrict the chest or parts of the arm. The shoulder joint is not released and exercised until specific instructions are given by the primary health care provider during a follow-up visit.
An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain? Administer prescribed analgesics around-the-clock. Avoid administering too much medication becausethe client is older. Administer prescribed pain medication only when the client requests it. Give pain medication to the client after providing care.
Administer prescribed analgesics around-the-clock. Pain associated with hip fracture is severe and must be carefully managed with around-the-clock dosing of pain medication to minimize energy loss in response to pain. The client may not request the medication even if they are in pain, and it should be offered at the prescribed time. Give pain medication prior to providing any type of care involved in moving the client.
A nurse is caring for a patient who has received carbidopa/levodopa. After administration of the first dose of the drug, the patient has developed gastrointestinal disturbances. Which nursing intervention should the nurse perform when caring for this patient? Administer the next drug dose with milk. Withhold the next dose of the drug. Observe alterations in blood pressure. Administer the next drug dose with meals.
Administer the next drug dose with meals. The nurse should administer the next drug dose with meals to manage gastrointestinal disturbances in a patient who has been administered antiparkinsonism drugs. Withholding the next dose of the drug, administering the next drug dose with milk, or observing alterations in the patient's blood pressure are not appropriate interventions when caring for a patient who is experiencing GI disturbances with the first dose of antiparkinsonism drugs.
A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Reassure the client that a headache is expected and will go away without treatment. Notify the physician; a headache is an early sign of worsening neurologic status.
Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Headaches are common after head injuries, so pain meds should be provided if needed. Codeine is an opioid sedative which would make the patient sleepy and mask neurological changes. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.
Emergency medical technicians transport a client to the emergency department and inform the nurse that the client fell from a two-story building. The comatose client has a large contusion on the left side of the chest, a hematoma in the left parietal area, and a compound fracture of the left femur. The client was intubated and is maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag. Which intervention by the nurse has the highest priority? Assessing the left leg Assessing the pupils Placing the client in Trendelenburg's position Assessing level of consciousness (LOC)
Assessing the left leg In this scenario, airway and breathing have been established, so the nurse's priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the left leg. Neurologic assessment of the pupils and LOC are secondary concerns to airway, breathing, and circulation. The nurse doesn't have enough data to warrant putting the client in Trendelenburg's position.
Which actions would the nurse expect to take for a client who has compartment syndrome? Select all that apply. One, some, or all responses may be correct. Assisting with splitting the cast Monitoring urine output Evaluating pain using a pain scale Applying splints to the injured part Placing cold compresses to the affected area
Assisting with splitting the cast Monitoring urine output Evaluating pain using a pain scale Compartment syndrome is increased pressure in a limited space, which compromises the compartmental blood vessels, nerves, and tendons. The cast may be split to reduce the external circumferential pressures. The nurse would assess urine output because the myoglobin released from damaged muscle cells may precipitate and cause obstruction in renal tubules. The nurse would evaluate the pain on a scale from 0 to 10; this helps plan care. Application of external pressure by splints, casts, and dressing to the injured area may worsen the client's symptoms. Application of cold compresses may result in vasoconstriction and exacerbate the symptoms.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? So that the patient will not have a respiratory arrest Because hypoxemia can create or worsen a neurologic deficit of the spinal cord To increase cerebral perfusion pressure To prevent secondary brain injury
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? Extreme thirst Intake and output Nutritional status Body temperature
Body temperature It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.
The nurse is caring for a client who states that he is suddenly having severe pain at a leg fracture site. The nurse notes increased swelling in the limb and difficulty palpating a pulse. The nurse suspects that the client may have: Compartment syndrome Fracture blisters Reflex sympathetic dystrophy Hematogenous osteomyelitis
Compartment syndrome The hallmark symptom of acute compartment syndrome is severe pain out of proportion to the original injury. One of the most important causes of compartment syndrome is bleeding and edema caused by fractures and bone surgery. Edema or swelling may make it difficult to palpate a pulse. Reflex sympathetic dystrophy, while characterized by pain out of proportion to the injury, does not exhibit decreased pulses. Fracture blisters are areas of epidermal necrosis with separation of epidermis from the underlying dermis by edema fluid. They are a warning sign of compartment syndrome. Hematogenous osteomyelitis originates with infectious organisms that reach the bone through the bloodstream.
A nurse is caring for 70-year-old patient who is undergoing anticholinergic drug therapy. The nurse should assess for which condition when caring for this elderly patient? Confusion and disorientation Choreiform movements Suicidal tendencies Psychotic episodes
Confusion and disorientation The nurse should assess for confusion and disorientation when caring for this elderly patient undergoing anticholinergic drug therapy. Individuals older than 60 years frequently develop increased sensitivity to anticholinergic drugs and require careful monitoring. Lower doses may also be required in such cases. Choreiform movements, suicidal tendencies, and psychotic episodes are serious adverse reactions associated with the use of levodopa, which is a dopaminergic drug.
A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? Elevating the stump for the first 24 hours Maintaining the client on complete bed rest Applying heat to the stump as the client desires Removing the pressure dressing after the first 8 hours
Elevating the stump for the first 24 hours Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.
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? Spontaneous pneumothorax Cardiac tamponade Pneumonia Fat emboli
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.
Due to her progressing osteoarthritis (OA), an 80 year-old woman is no longer able to perform her activities of daily living without assistance. Which of the following phenomena most likely underlies the woman's situation? Inappropriate T-cell mediated immune responses have resulted in articular cartilage degeneration. Loss of articular cartilage and synovitis has resulted from inflammation caused when joint cartilage attempted to repair itself. Excessive collagen deposits have accumulated in the woman's synovial joints. Bone overgrowth in synovial joints has resulted in fusing of adjacent bones that normally articulate.
Loss of articular cartilage and synovitis has resulted from inflammation caused when joint cartilage attempted to repair itself.Explanation: The joint changes associated with osteoarthritis, which include a progressive loss of articular cartilage and synovitis, results from the inflammation caused when cartilage attempts to repair itself, creating osteophytes or spurs. These changes are accompanied by joint pain, stiffness, limitation of motion, and in some cases by joint instability and deformity. Immune etiology is more associated with rheumatoid arthritis and collagen deposits are characteristic of scleroderma. Bones do not tend to fuse in the pathogenesis of OA.
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. Withhold opioid pain medication to prevent ileus. Maintain NPO (nothing by mouth) status for surgical repair. Sit the client upright in a padded chair for meals.
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 client asks the nurse why her hip fracture (head of the femur) bone has died (osteonecrosis). The nurse responds based on which pathophysiologic principle? All fractured bones interrupt blood supply and thereby result in death of bone no matter where it is located. Most of the time when the head of the femur breaks, the entire neck region is disconnected to the rest of the bone, so the blood vessels are severed. Since the head of the femur has only limited collateral circulation, interruption in the blood flow from the fracture causes necrosis and irreversible damage. When the femur head breaks, it dislocates and crushes the surrounding area causing the blood vessels to be occluded.
Since the head of the femur has only limited collateral circulation, interruption in the blood flow from the fracture causes necrosis and irreversible damage. Bone has a rich blood supply that varies from site to site. The flow in the medullary portion of bone originates in nutrient vessels from an interconnecting plexus that supplies the marrow, trabecular bone, and endosteal half of the cortex. Some bony sites, such as the head of the femur, have only limited collateral circulation, so that interruption of the flow, such as with a hip fracture, can cause necrosis of a substantial portion of medullary and cortical bone and irreversible damage. Not all fractures interrupt blood supply to the bone. It is not common for the entire head of the femur to break off, thus leaving the area with no blood supply.
Which condition occurs when blood collects between the dura mater and arachnoid membrane? Intracerebral hemorrhage Epidural hematoma Extradural hematoma Subdural hematoma
Subdural hematoma A subdural hematoma is a collection of blooding between the dura mater and brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.
A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? Fever and chest pain Positive Homans sign Loss of sensation in the operative leg Tachycardia and petechiae over the chest
Tachycardia and petechiae over the chest Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurological dysfunction; it is not an indication of a fat embolism.
The nurse is caring for client who has been living with Parkinson disease for the past 10 years and is being treated with levodopa-carbidopa. The client often leaves the unit with family for extended periods. What should the nurse prioritize when teaching the client? It is essential that you eat a healthy diet with adequate amounts of protein if dining out. Your medication needs to be taken at equal intervals to reduce symptom fluctuation. Frequent assessments are needed to prevent complications related to your condition. Due to your risk for falls it is recommended you do not leave the unit with family.
Your medication needs to be taken at equal intervals to reduce symptom fluctuation. A later adverse effect of levodopa treatment is on-off phenomenon, which reflects the timing of drug administration. If the client does not receive doses on time, this will increase the amount of negative symptoms experienced. The importance of symptom control through proper timing of medications is a priority over routine assessments related to a condition the client has had for 10 years. Though the client may be at risk for falls, this does not mean the client should not leave the unit as this risk can be mitigated. The client will not want to consume excess meat proteins as these can interfere with the action of levodopa.
A client has a diagnosis of Parkinson disease, and the health care provider will prescribe carbidopa-levodopa. Before drug therapy, the client should be carefully assessed for the presence of: macular degeneration. closed-angle glaucoma. peptic ulcer disease. diabetes mellitus.
closed-angle glaucoma. Carbidopa-levodopa is contraindicated in a person with closed-angle glaucoma. However, it can be used in a person with open-angle glaucoma if intraocular pressure is closely monitored and controlled. Carbidopa-levodopa can be used by persons with peptic ulcer disease and diabetes mellitus, but it may exacerbate the symptoms of these disorders.
The nurse is performing passive range-of-motion exercises with a client on a rehabilitation unit. The nurse takes the client's right hand and touches the thumb to each finger. Later, the nurse documents this range-of-motion activity as inversion. opposition. palmar flexion. supination.
opposition. The nurse should document the activity as opposition, which is defined as touching the thumb to each finger on a hand. Inversion is turning the sole of the foot inward. Palmar flexion is bending the hand in the direction of the palm. Supination is rotation of the forearm so that the palm of the hand is facing up.
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 brace cast All options are correct.
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.
An 80-year-old client is admitted to the hospital with a displaced intracapsular hip fracture. The physician explains to the client's family that this type of fracture is best treated by: surgical hip replacement and early mobilization. open reduction and internal fixation. nonoperative treatment. external fixation.
surgical hip replacement and early mobilization. Displaced intracapsular fractures in the elderly are usually best treated by surgical hip replacement and early mobilization. Young, healthy people are treated by reduction of the fracture and internal fixation. Intertrochanteric fractures are usually treated with open reduction and internal fixation. External fixation devices are not used for hip fractures.
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. Administer pain medication per orders. Assess pedal pulses. Assess the diameter of the thigh every 15 minutes.
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 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? Fracture Contusion Sprain Strain
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.
Which is an indicator of neurovascular compromise? Warm skin temperature Diminished pain Pain upon active stretch Capillary refill of more than 3 seconds
Capillary refill of more than 3 seconds Capillary refill of more than 3 seconds is an indicator of neurovascular compromise. Other indicators include cool skin temperature, pale or cyanotic color, weakness, paralysis, paresthesia, unrelenting pain, pain upon passive stretch, and absence of feeling. Cool skin temperature is an indicator of neurovascular compromise. Unrelenting pain is an indicator of neurovascular compromise. Pain upon passive stretch is an indicator of neurovascular compromise.
A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate? Establishing an intermittent catheterization routine every 4 hours Managing spasticity with range-of-motion exercises and medications Establishing an ambulation program using short leg braces Preventing autonomic dysreflexia by preventing bowel impaction
Establishing an intermittent catheterization routine every 4 hours The paraplegic client with an L1-L2 injury will demonstrate flaccid paralysis. Developing an intermittent catheterization routine offers a way of manually draining the bladder, eliminating the need for an indwelling urinary catheter. With an injury at L1-L2, ambulation may be possible with long leg braces but not with short leg braces. Spasticity and autonomic dysreflexia are seen in clients with upper motor injuries above T6, not L1-L2 injuries.
Which type of cast or splint will the nurse expect to see on a child with a fractured femur? Cylinder Hip spica Prefabricated knee Robert Jones
Hip spica A hip spica cast is now mainly used for femur fractures in children. A cylinder cast is used for knee fractures because it extends from the groin to the malleoli of the ankle. A prefabricated knee splint is a commonly used cast for lower extremity injuries. A Robert Jones dressing is composed of bulky padding materials, splints, and elastic wrap or stockinette used for lower extremity injuries.
A nurse is caring for a client who has been prescribed entacapone for the treatment of Parkinson disease. The client informs the nurse that he is taking MAOI antidepressants for the management of depression. The nurse would anticipate which effect from the administration of these two drugs? Increased risk of toxicity of both drugs Increased anticholinergic effects Increased psychotic behavior Increased risk of cardiac symptoms
Increased risk of toxicity of both drugs The nurse should anticipate the risk of toxicity of both drugs when entacapone and MAOI antidepressants are given. Increased anticholinergic effects and increased psychotic behavior are the effects of the interaction of amantadine and haloperidol with cholinergic blocking drugs. Increased risk of cardiac symptoms is the effect of the interaction of adrenergic drugs with tolcapone.
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 The client who sustained a clavicle fracture The client using ice to control pain in the extremity
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 70 year-old male has been diagnosed with a stroke that resulted in an infarct to his cerebellum. Which clinical finding would be most closely associated with cerebellar insult? Flaccid loss of muscle tone Difficulty starting movement, stopping movement, and maintaining rhythmic movements. Tremor, rigidity, and bradykinesia Unsteady gait and difficulty speaking and swallowing
Unsteady gait and difficulty speaking and swallowing An unsteady gait characterizes cerebellar ataxia and both swallowing and speaking are partly the domain of the cerebellum. Flaccid loss of muscle tone is not noted to accompany cerebellar insult. Difficulties with starting movement, stopping movement, and maintaining rhythmic movements are indicative of basal ganglia disorders. Tremor, rigidity, and bradykinesia are associated with Parkinson disease.
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client reports a headache. reports generalized weakness. sleeps for short periods of time. vomits.
vomits Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.
