PrepU Chapter 40: Musculoskeletal Care

A patient arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the patient to describe the pain? -Similar to "muscle cramps" -Sharp and piercing -Sore and aching -A dull, deep, boring ache

-Sharp and piercing

Following a total knee replacement, the surgeon orders a continuous passive motion (CPM) device. The client asks about the purpose of this treatment. What is the best response by the nurse? -"CPM increases range of motion of the joint." -"CPM strengthens the muscles of the leg." -"CPM delivers analgesic agents directly into the joint." -"CPM prevents injury by limiting flexion of the knee."

-"CPM increases range of motion of the joint." CPM increases circulation and range of motion of the knee joint.

When discussing physical activities with the client who has just undergone a right total hip replacement, which instruction should the nurse provide? -"Limit hip flexion to 90 degrees." -"Perform rotation exercises each day." -"Intermittently cross and uncross your legs several times each day." -"Avoid weight bearing until the hip is completely healed."

-"Limit hip flexion to 90 degrees." The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. The hip should not bend more than 90 degrees. Ambulation begins the day following surgery, and weight bearing ambulation may not be restricted, depending on the type of prosthesis.

The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective? -"Metal pins will go through my skin to the bone." -"I will wear a boot with weights attached." -"A belt will go around my pelvis and weights will be attached." -"The traction can be removed once a day so I can shower."

-"Metal pins will go through my skin to the bone." In skeletal traction, metal rods or pins are used to apply continuous traction directly to the bone. Weights are used to apply the traction. Casts, external fixators, or splints are used when the traction is discontinued.

A client has a plaster cast applied to the left leg. Which comment by the client following the procedure should the nurse address first? -"My toes are stiff." -"My toes are pink." -"My cast is still wet." -"My pain is a 3."

-"My toes are stiff." Compartment syndrome is characterized by neurovascular compromise. Stiffness of the toes may be a preliminary finding that the client is having trouble with motor function.

Which instruction should the nurse include when teaching the client following hip replacement surgery? (Select all that apply.) -"You may cross your legs at the ankles only." -"Place pillows between your legs when you lay on your side." -"Avoid bending forward when sitting in a chair." -"Use a raised toilet seat and high-seated chair." -"It is okay to briefly flex the hip to put on your clothes."

-"Place pillows between your legs when you lay on your side." -"Avoid bending forward when sitting in a chair." -"Use a raised toilet seat and high-seated chair." The client following post hip replacement should not cross the legs, even at the ankle. He or she should avoid bending forward when sitting in a chair, avoid flexing the hip when dressing, and use a raised toilet seat. A pillow should be placed between the legs when side-lying.

The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for? -An open reduction -A fasciotomy -A total hip replacement -A total knee replacement

-A fasciotomy A treatment option for compartment snydrome is fasciotomy.

Which nursing action would help prevent deep vein thrombosis in a client who has had an orthopedic surgery? -Instruct about using client-controlled analgesia, if prescribed -Instruct about exercise, as prescribed -Apply antiembolism stockings -Apply cold packs

-Apply antiembolism stockings Applying antiembolism stockings helps prevent deep vein thrombosis (DVT) in a client who is immobilized due to orthopedic surgery. Regular administration of analgesics controls and prevents escalation of pain, while ROM exercises help maintain muscle strength and tone and prevent contractions. On the other hand, cold packs are applied to help reduce swelling; cold does not prevent deep vein thrombosis.

A client has a Fiberglass cast on the right arm. Which action should the nurse include in the care plan? -Keeping the casted arm warm by covering it with a light blanket -Avoiding handling the cast for 24 hours or until it is dry -Evaluating pedal and posterior tibial pulses every 2 hours -Assessing movement and sensation in the fingers of the right hand

-Assessing movement and sensation in the fingers of the right hand The nurse should assess a casted arm every 2 hours for finger movement and sensation to make sure the cast isn't restricting circulation. To reduce the risk of skin breakdown, the nurse should leave a casted arm uncovered, which allows air to circulate through the cast pores to the skin below. Unlike a plaster cast, a Fiberglass cast dries quickly and can be handled without damage soon after application. The nurse should assess the brachial and radial pulses distal to the cast — not the pedal and posterior tibial pulses, which are found in the legs.

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority? -Assessing the extremity for neurovascular integrity -Keeping the client from sliding to the foot of the bed -Keeping the ropes over the center of the pulley -Ensuring that the weights hang free at all times

-Assessing the extremity for neurovascular integrity Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.

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 group of students is studying for a test on traction. The students demonstrate understanding of the types of traction when they identify which of the following as an example of skin traction? -Crutchfield tongs -Thomas splint -Buck's -Balanced suspension

-Buck's An example of skin traction is Buck's traction. Crutchfield tongs, a Thomas splint, or balanced suspension traction are types of skeletal traction.

A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client? -Assisting with range-of-motion and isometric exercises. -Changing the client's position within prescribed limits. -Administering prescribed analgesics. -Applying warm compresses.

-Changing the client's position within prescribed limits. Changing the position of a client within prescribed limits helps relieve pressure on bony areas and promotes comfort. Analgesics help to relive pain but may not help relieve pressure on bony areas. Warm compresses aid blood circulation. The client should not exercise while on traction unless prescribed to regain strength in the affected limb.

The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) -Decreased sensory function -Excruciating pain -Loss of motion -Capillary refill less than 3 seconds -2+ peripheral pulses in the affected distal pulse

-Decreased sensory function -Excruciating pain -Loss of motion Clinical manifestations include dusky, pale appearance of the exposed extremity; cool skin temperature; delayed capillary refill; paresthesia; and unrelenting pain not relieved by position changes, ice, or analgesia. A hallmark sign is pain that occurs or intensifies with passive range of motion (Johnston-Walker & Hardcastle, 2011). The patient may complain that the cast, brace, or splint is too tight. The primary provider must be notified immediately.

A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain? -Elevate the affected extremity and use cold applications. -Breathe deeply and cough every 2 hours until ambulation is possible. -Do ROM exercises as indicated. -Apply antiembolism stockings as indicated.

-Elevate the affected extremity and use cold applications. Elevating the affected extremity and using cold applications reduce swelling. Deep breathing and coughing helps with maintenance of effective respiratory rate and depth. ROM exercises maintain full ROM of unaffected joints. Antiembolism stockings help prevent deep vein thrombosis (DVT).

Which intervention would the nurse implement with the client in skeletal traction? Select all that apply. -Apply 8-pound weight to the rope. -Ensure the pins or wires are covered with caps. -Remove foam boot and inspect skin daily. -Position trapeze within the client's reach. -Instruct the client on isometric exercises for immobilized extremity.

-Ensure the pins or wires are covered with caps. -Position trapeze within the client's reach. -Instruct the client on isometric exercises for immobilized extremity. Nursing care of the client in skeletal traction includes ensuring the trapeze is within the client's reach and the pins or wires are covered with caps. The nurse instructs the client on isometric exercises for the immobilized extremity. A foam boot is used with Buck's traction (skin traction) not skeletal traction. An 8-pound weight is used with Buck's traction, whereas a 15- to 25-pound weight is applied in skeletal traction.

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for? -Atelectasis -Hypovolemia -Pulmonary embolism -Urinary tract infection

-Pulmonary embolism Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism.

A 68-year-old female client who had a total hip replacement is to be discharged because her healing is almost complete. Which of the following would be most important for this client? -Advising the client to avoid red meat -Urging her to keep the affected limb in an elevated position -Educating the client about the effects of menopause -Exploring factors related to the client's home environment

-Exploring factors related to the client's home environment Exploring factors related to the older adult client's home environment and determining a plan for continued rehabilitation before discharge is most important. The client should be encouraged to eat foods rich in protein, calcium, and vitamin D. Because the healing is almost complete, the client need not always keep the affected limb elevated unless prescribed to do so. Because the client is in her late 60s, she is most likely to have already undergone menopause. Therefore, educating her about the effects of menopause is not as important.

Which intervention should the nurse implement with the client who has undergone a hip replacement? -Instruct the client to avoid internal rotation of the leg. -Place the client in high Fowler's position for meals. -Have the client bend forward to rise from the chair. -Adduct the legs by placing a pillow between the legs.

-Instruct the client to avoid internal rotation of the leg. The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. A pillow is used to keep the legs in abduction. The hip should not bend more than 90 degrees when seated. The head of bed should be kept at 60 degrees or less.

Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery? -It provides active range of motion. -It promotes healing by increasing circulation and movement of the knee joint. -It promotes healing by immobilizing the knee joint. -It prevents infection and controls edema and bleeding.

-It promotes healing by increasing circulation and movement of the knee joint. A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.

A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for? -Left hip arthroplasty -Left hip arthroscopy -Open reduction and internal fixation of the left hip. -Closed reduction of the left hip.

-Left hip arthroplasty Clients with arthritis, trauma, hip fracture, or a congenital deformity may have an arthroplasty, or reconstruction of the joint. This procedure uses an artificial joint that restores previously lost function and relieves pain. An arthroscopy is not used to reconstruct a diseased hip. A closed reduction is not an invasive surgical procedure and would not be used to reconstruct the hip. An open reduction and internal fixation is not the treatment for reconstruction of the hip related to a diseased hip.

A client has undergone an external fixation. Which actions would be the priority for this client? -Maintaining pin care. -Planning the client's diet. -Monitoring the client's urine output. -Monitoring the client's blood pressure.

-Maintaining pin care. Pin care is a priority for a client with external fixation, because pin sites are entry points for infection. The nurse should also monitor redness, drainage, and tenderness at the site. Planning the client's diet and monitoring the client's urine output and blood pressure, although necessary, are not as important as maintaining pin care.

The nurse assesses a clientafter total right hip arthroplasty and observes a shortening of the extremity. The client reports severe pain in the right side of the groin. What is the priority action of the nurse? -Apply Buck's traction. -Notify the health care provider. -Externally rotate the extremity. -Bend the knee and rotate the knee internally.

-Notify the health care provider. If any clinical manifestations of dislocation of the prosthesis occur, including acute groin pain in the affected hip or shortening of the affected extremity, the nurse (or the client, if at home) must immediately notify the surgeon, because the hip must be reduced and stabilized promptly so that the leg does not sustain circulatory and nerve damage. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. As the muscles and joint capsule heal, the chance of dislocation diminishes. Stresses to the new hip joint should be avoided for the first 8 to 12 weeks, when the risk of dislocation is greatest.

A client's fracture was reduced by surgically exposing the bone and realigning it. What type of treatment does the nurse identity this as? -Buck's traction -Skeletal traction -Internal fixation -Open reduction

-Open reduction In an open reduction, the bone is surgically exposed and realigned. Buck's traction is a type of skin traction that provides pulling on the structures. Skeletal traction is applied directly to the bone using a wire, pin, or cranial tongs. Internal fixation involves the use of metal screws, plates, rods, nails or pins to stabilize a reduced fracture.

Which actions by the nurse demonstrate an understanding of caring for a client in traction? Select all that apply. -Placing a trapeze on the bed -Ensuring that the weights are hanging freely -Assessing the client's alignment in the bed -Removing skeletal traction to turn and reposition the client -Frequently assessing pain level

-Placing a trapeze on the bed -Ensuring that the weights are hanging freely -Assessing the client's alignment in the bed -Frequently assessing pain level The weights must hang freely, with the client in good alignment in the center of the bed. The nurse should frequently monitor pain, as uncontrolled pain may be a sign of a complication. The client will be able to assist with alignment and bed mobility if a trapeze is placed on the bed. Skeletal traction should never be interrupted.

Which is an inaccurate principle of traction? -The weights are not removed unless intermittent treatment is prescribed. -The weights must hang freely. -The client must be in good alignment in the center of the bed. -Skeletal traction is interrupted to turn and reposition the client.

-Skeletal traction is interrupted to turn and reposition the client. Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely, with the client in good alignment in the center of the bed.

Which principle applies to the client in traction? -Weights should rest on the bed. -Skeletal traction is never interrupted. -Knots in the ropes should touch the pulley. -Weights are removed routinely.

-Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted. To be effective, the weights must hang freely and not rest on the bed or floor. Knots in the rope or the footplate must not touch the pulley or the foot of the bed. Traction must be continuous to be effective in reducing and immobilizing fractures.

Which is not a guideline for avoiding hip dislocation after replacement surgery. -The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. -Keep the knees apart at all times. -Put a pillow between the legs when sleeping. -Never cross the legs when seated.

-The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.

A patient had a total left hip arthroplasty. What clinical manifestation would indicate to the nurse that the prosthesis is dislocated? -The left leg is internally rotated. -The leg length is the same as the right leg. -The patient has discomfort when moving in the bed. -Diminished peripheral pulses on the affected extremity

-The left leg is internally rotated. The nurse must monitor for signs and symptoms of dislocation of the prosthesis, which include abnormal external or internal rotation of the affected extremity.

Which statement describes external fixation? -The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. -The surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. -The bone is restored to its normal position by external manipulation. -The bone is surgically exposed and realigned.

-The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. In external fixation, the surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. In internal fixation, the surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. In closed reduction, the bone is restored to its normal position by external manipulation. In open reduction, the bone is surgically exposed and realigned.

A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for? -Arthrodesis -Hemiarthroplasty -Total arthroplasty -Osteotomy

-Total arthroplasty A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplastyis the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.

The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene? -Body aligned opposite to line of traction pull -Weights hanging and touching the floor -Pulleys without evidence of the obstruction -Ropes freely moving over pulleys

-Weights hanging and touching the floor When checking traction equipment, the weights should be freely hanging. Weights that touch the floor require the nurse to intervene. The body should be aligned in an opposite line to the pull of the traction. The ropes should be freely moving over unobstructed pulleys.

The client who had a total hip replacement was discharged home and developed acute groin pain in the affected leg, shortening of the leg, and limited movement of the fractured leg. The nurse interprets these findings as indicating which of the following complications? a) Dislocation of the hip b) Avascular necrosis of the hip c) Re-fracture of the hip d) Contracture of the hip

Dislocation of the hip Explanation: Manifestations of a dislocated hip prosthesis are increased pain at the surgical site, acute groin pain in the affected leg, shortening of the leg, abnormal external or internal rotation, and limited movement of the fractured leg. The client may report a "popping" sensation in the hip.

The nurse teaches the patient which of the following interventions in order to avoid hip dislocation after replacement surgery? a) Keep the knees together at all times b) Never cross the affected leg when seated c) Bend forward only when seated in a chair d) Avoid placing a pillow between the legs when sleeping

Never cross the affected leg when seated Explanation: Crossing the affected leg may result in dislocation of the hip joint after total hip replacement. The patient should be taught to keep the knees apart at all times. The patient should be taught to put a pillow between the legs when sleeping. The patient should be taught to avoid bending forward when seated in a chair.