Prep-U Ch. 62: Caring for Clients with Traumatic Musculoskeletal Injuries

A patient has suffered a femoral shaft fracture in an industrial accident. What is an immediate nursing concern for this patient? A. Hypovolemic shock B. Infection C. Knee and hip dislocation D. Pain resulting from muscle spasm

A. Hypovolemic shock - Frequently, the patient develops shock, because the loss of 1,000 mL of blood into the tissues is common with fractures of the femoral shaft (ENA, 2013).

There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head? A. avascular necrosis B. fat embolism C. pulmonary embolism D. shock

A. avascular necrosis - Avascular necrosis is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head.

A client is to undergo surgery to repair a ruptured Achilles tendon and application of a brace. The client demonstrates understanding of activity limitations when stating that a brace must be worn for which length of time? A. 2 to 4 weeks B. 6 to 8 weeks C. 10 to 12 weeks D. 14 to 16 weeks

B. 6 to 8 weeks - Following surgical repair for a ruptured Achilles tendon, the client wears a brace or cast for 6 to 8 weeks.

A nurse is assigned to support a patient while a cast is being applied to treat a greenstick fracture. The nurse documents that this fracture is classified as what type of fracture? A. Closed B. Incomplete C. Stress D. Compression

B. Incomplete - A greenstick fracture involves a break through only part of the cross-section of the bone.

Six weeks after an above-the-knee amputation (AKA), a client returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the client reports symptoms of phantom pain. What should the nurse tell the client to do to reduce the discomfort of the phantom pain? A. Apply intermittent hot compresses to the area of the amputation. B. Avoid activity until the pain subsides. C. Take opioid analgesics as prescribed. D. Elevate the level of the amputation site.

C. Take opioid analgesics as prescribed. - Opioid analgesics may be effective in relieving phantom pain. Heat, immobility, and elevation are not noted to relieve this form of pain.

A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse? A. "Your left toes have been amputated." B. "The pain is really from the nerves in the upper leg." C. "Pain medication usually does not help this type of pain." D. "Describe the pain and rate it on the pain scale."

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

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this? A. Compound B. Depressed C. Impacted D. Comminuted

D. Comminuted - A comminuted fracture may require open reduction and internal fixation. A compound fracture is one in which damage also involves the skin or mucous membranes. A depressed fracture is one in which fragments are driven inward. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

A nurse is preparing to discharge a client from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage what action? A. Apply heat for the first 24 to 48 hours after the injury. B. Maintain the ankle in a dependent position. C. Exercise hourly by performing rotation exercises of the ankle. D. Keep an elastic compression bandage on the ankle.

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

Which type of fracture is one in which the skin or mucous membrane wound extends to the fractured bone? A. Compound B. Complete C. Incomplete D. Simple

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

Which of the following musculoskeletal injuries is manifested by acromioclavicular joint pain? A. Rotator cuff tears B. Epicondylitis C. Heterotopic ossification D. Acute compartment syndrome

A. Rotator cuff tears - Key assessment findings related to rotator cuff tears include acromioclavicular joint pain, limited range of motion, and muscle weakness. Epicondylitis (tennis elbow) is manifested by pain that usually radiates down the extensor surface of the forearm and generally is relieved with rest and avoidance of the aggravating activity. Heterotopic ossification is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur.

Which is not one of the general nursing measures employed when caring for the client with a fracture? A. cranial nerve assessment B. administering analgesics C. providing comfort measures D. assisting with ADLs

A. cranial nerve assessment - Cranial nerve assessment would only be carried out for head-related injuries or diseases. General nursing measures include administering analgesics, providing comfort measures, assisting with ADLs, preventing constipation, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing client for self-care.

The type of fracture described as having one side of the bone broken and the other side bent would be: A. greenstick. B. oblique. C. spiral. D. transverse.

A. greenstick. - A greenstick fracture is the type of fracture described as having one side of the bone broken and the other side bent. An oblique fracture occurs at an angle across the bone. A spiral fracture is a fracture that twists around the shaft of the bone. A transverse fracture is a fracture that is straight across the bone.

A client who was injured while playing basketball reports an extremely painful elbow, which is very edematous. What type of injury has the client experienced? A. sprain B. strain C. contusion D. All options are correct.

A. sprain - Sprains are injuries to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. Sprains are injuries to the ligaments surrounding a joint.

The nurse is monitoring a patient who sustained a fracture of the left hip. The nurse should be aware that which kind of shock can be a complication of this type of injury? A. Cardiogenic B. Hypovolemic C. Neurogenic D. Septic

B. Hypovolemic - In a client with a pelvic fracture, the nurse should be aware of the potential for hypovolemic shock resulting from hemorrhage. Cardiogenic shock, in which the heart cannot pump enough blood to meet the body's needs, often arises from severe myocardial infarction. Neurogenic shock is often a consequence of spinal cord injury and resulting loss of sympathetic nervous system function. Septic shock results from body-wide infection.

A client is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The client has an open fracture on his tibia. The wound is highly contaminated and there is extensive soft- tissue damage. How would this client's fracture likely be graded? A. Grade I B. Grade II C. Grade III D. Grade IV

C. Grade III - Open fractures are graded according to the following criteria. Grade I is a clean wound less than 1 cm long. Grade II is a larger wound without extensive soft-tissue damage. Grade III is highly contaminated, has extensive soft-tissue damage, and is the most severe. There is no grade IV fracture.

A client is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. What is the most plausible explanation for this client's signs and symptoms? A. Subluxated right hip B. Right hip contusion C. Hip strain D. Traumatic hip dislocation

D. Traumatic hip dislocation - Signs and symptoms of a traumatic dislocation include acute pain, change in positioning of the joint, shortening of the extremity, deformity, and decreased mobility. A subluxation would cause moderate deformity, or possibly no deformity. A contusion or strain would not cause obvious deformities.

How long does it take for the bone to regain its former structural strength after a break? A. 1 year B. 8 months C. 6 months D. 2 years

A. 1 year - About 1 year of healing must pass before bone regains its former structural strength.

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. In addition to the regular postoperative assessments prescribed by policy, what assessment is completed every 30 minutes for several hours? A. neurovascular B. orientation C. head-to-toe D. neurological

A. neurovascular - The nurse should perform neurovascular assessments every 30 minutes for several hours, and then at least every 2 to 4 hours for the next 1 or 2 days to detect complications.

An emergency department client is diagnosed with a hip dislocation. The client's family is relieved that the client has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurse's statement? A. The longer the joint is displaced, the more difficult it is to get it back in place. B. The client's pain will increase until the joint is realigned. C. Dislocation can become permanent if the process of bone remodeling begins. D. Avascular necrosis may develop at the site if it is not promptly resolved.

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

A client with a traumatic amputation of the right lower leg is refusing to look at the leg. Which action by the nurse is most appropriate? A. Provide wound care without discussing the amputation. B. Request a referral to occupational therapy. C. Encourage the client to perform range-of-motion (ROM) exercises to the right leg. D. Provide feedback on the client's strengths and available resources.

D. Provide feedback on the client's strengths and available resources. - The nurse should encourage the client to look at, and assist with, care of the residual limb. Providing feedback on the client's strengths and resources may allow the client to start to adapt to the body image and lifestyle change. The nurse should also allow time for the client to discuss their feelings related to the amputation. Requesting a referral to occupational therapy and encouraging the client to perform ROM exercises are appropriate but do not address the emotional aspect of losing an extremity.

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? A. Chest strapping B. Mechanical ventilation C. Coughing and deep breathing with pillow splinting D. Thoracentesis

C. 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.

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? A. Assess vital signs and level of consciousness. B. Administer pain medication per orders. C. Assess pedal pulses. D. Assess the diameter of the thigh every 15 minutes.

A. 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.

Which term refers to the failure of fragments of a fractured bone to heal together? A. Dislocation B. Subluxation C. Nonunion D. Malunion

C. Nonunion - When nonunion occurs, the client reports persistent discomfort and movement at the fracture site. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Malunion refers to growth of the fragments of a fractured bone in a faulty position, forming an imperfect union.

A patient sustains a fracture of the arm. When does the nurse anticipate pendulum exercise should begin? A. As soon as tolerated, after a reasonable period of immobilization B. In 2 to 3 weeks, when callus ossification prevents easy movements of bony fragments C. In about 4 to 5 weeks, after new bone is well established D. In 2 to 3 months, after normal activities are resumed

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

A client who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge? A. Client can demonstrate safe use of assistive devices. B. Client has a healed, nontender, nonadherent scar. C. Client can perform activities of daily living independently. D. Client is free of pain.

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

The femur fracture that commonly leads to avascular necrosis or nonunion because of an abundant supply of blood vessels in the area is a fracture of the: A. Condylar area. B. Femoral neck. C. Shaft of the femur. D. Trochanteric region.

B. Femoral neck. - A fracture of the neck of the femur may damage the vascular system and the bone will become ischemic. Therefore, a vascular necrosis is common.

An elite high school football player has been diagnosed with a shoulder dislocation. The client has been treated and is eager to resume his role on his team, stating that he is not experiencing pain. What should the nurse emphasize during health education? A. The need to take analgesia regardless of the short-term absence of pain B. The importance of adhering to the prescribed treatment and rehabilitation regimen C. The fact that he has a permanently increased risk of future shoulder dislocations D. The importance of monitoring for intracapsular bleeding once he resumes playing

B. The importance of adhering to the prescribed treatment and rehabilitation regimen - Clients who have experienced sports-related injuries are often highly motivated to return to their previous level of activity. Adherence to restriction of activities and gradual resumption of activities need to be reinforced. Appropriate analgesia use must be encouraged, but analgesia does not necessarily have to be taken in the absence of pain. If healing is complete, the client does not likely have a greatly increased risk of reinjury. Dislocations rarely cause bleeding after the healing process.

A nurse is caring for a client who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the client does what action to prevent common complications associated with a hip fracture? A. Avoid requesting analgesia unless pain becomes unbearable. B. Use supplementary oxygen when transferring or mobilizing. C. Increase fluid intake and perform prescribed foot exercises. D. Remain on bed rest for 14 days or until instructed by the orthopedic surgeon.

C. Increase fluid intake and perform prescribed foot exercises. - Deep vein thrombosis (DVT) is among the most common complications related to a hip fracture. To prevent DVT, the nurse encourages intake of fluids and ankle and foot exercises. The client should not be told to endure pain; a proactive approach to pain control should be adopted. While respiratory complications commonly include atelectasis and pneumonia, the use of deep-breathing exercises, changes in position at least every 2 hours, and the use of incentive spirometry help prevent the respiratory complications more than using supplementary oxygen. Bed rest may be indicated in the short term, but is not normally required for 14 days.