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Final Exam Questions (NUR 2790) CHAPTER 51: CARE OF PATIENTS WITH MUSCULOSKELETAL TRAUMA (30% OF FINAL EXAM) MULTIPLE CHOICE
- A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider?
- Blood pressure increases to 130/86 mm Hg - Traction weights are resting on the floor
- Oozing of clear fluid is noted at the pin site
- Capil lary refill is less than 3 secon ds ANS: B The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The clients blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time. Weights should not be removed without a prescription. They should not be lifted manually or allowed to rest on the floor. Weights should be freely hanging at all times. Inspect the skin Q8H for S/S of irritation or inflammation. Remove the belt or boot that is used for skin traction Q8H to inspect under the device.
- A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)?
- Assess distal pulses for potential compartment syndrome.
- Turn the client every 3 to 4 hours to promote cast drying. - Use a cloth-covered pillow to elevate the clients leg.
- Handle the cast with your fingertips to prevent indentations. ANS: C When delegating care to a UAP for a client with a wet plaster cast, the UAP should be directed to ensure that the extremity is elevated on a
cloth pillow instead of a plastic pillow to promote drying. The client should be assessed for impaired arterial circulation, a complication of compartment syndrome; however, the nurse should not delegate assessments to a UAP. The client should be turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Providers should handle the cast with the palms of the hands to prevent indentations.
- A nurse obtains the health history of a client with a fractured femur. Which factor identified in the clients history should the nurse recognize as an aspect that may impede healing of the fracture?
- Sedentary lifestyle
- A 30 pack-year smoking history
- Prescribed oral contraceptives - Pagets disease ANS: D Pagets disease and bone cancer can cause pathologic fractures such as a fractured femur that do not achieve total healing. The other factors do not impede healing but may cause other health risks. Causes of Pathological Fractures :
- Osteogenesis imperfecta
- Rickets
- Osteomalacia
- Osteoporosis
- Hyperparathyroidism
- Cushing’s syndrome
- Paget’s disease : a chronic form of osteitis (osteitis deformans) of unknown cause affecting older people, causing thickening and hypertrophy (enlargement) of the long bones and deformity of the flat bones
- Neoplasms
- Cystic bone disease
- Primary benign bone tumor
- Primary malignant bone tumor
- Infection
- Irradiation
- An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first? - Assess the pedal pulses.
- Apply oxygen by nasal cannula.
- Increase the IV flow rate.
- L o o s e n t h e
a high-Fowlers position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless. Fat Embolism Syndrome (FES) : a fracture complication in which fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hrs after an injury
- Hip fracture patients are at highest risk (24 to 72 hrs after injury or surgery)
- 95% of FE come from the long bones
- May be misdiagnosed as a PE from a blood clot
- Early S/S : hypoxemia, dyspnea, tachypnea
- Later S/S : headache, lethargy, agitation, confusion, decreased LOC, seizures, vision changes, retinal hemorrhage, mild thrombocytopenia - Last S/S : petechiae (macular, measles-like rash) classic manifestation
- Treatment : bedrest, gentle handling, oxygen, IV hydration, steroid therapy, fracture immobilization
- A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis?
- An 18-year-old male athlete with a fractured clavicle
- A 36-year old female with type 2 diabetes and fractured ribs
- A 55-year-old woman prescribed aspirin for rheumatoid arthritis - A 74-year-old man who smokes and has a fractured pelvis ANS: D Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis (stasis of blood caused by venous congestion), prolonged immobility, surgical procedure longer than 30 mins, cancer or chemotherapy, and heart disease. The other clients do not have risk factors for DVT.
- A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client?
- Remove the traction when re-positioning the client.
- Inspect the clients skin when performing a bed bath.
- Provide pin care by using alcohol wipes to clean the sites.
- Ensure that the weights remain freely hanging at all times. ANS: D Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the clients skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP.
- A nurse notes crepitation when performing range-of-motion
exercises on a client with a fractured left humerus. Which action should the nurse take next?
- Immobilize the left arm.
- Assess the clients distal pulse.
- Monitor for signs of infection.
- Ad min iste r pre scri bed ster oid s. AN S: A A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the clients arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.
- A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety? - Meperidine (Demerol) 50 mg IV every 4 hours
- Patient-controlled analgesia (PCA) with morphine sulfate
- Percocet 2 tablets orally every 6 hours PRN for pain
- Ibuprofe n elixir every 8 hours for first 2 days ANS: A Meperidine (Demerol) should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this clients pain management. The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (Beers List) : guidelines to help improve the safety of prescribing medications for older adults
- Meperidine (Demerol) , opioid analgesic, appears on the Beers List (morphine is recommended instead)
- PCA w/ morphine , fentanyl , or hydromorphone (Dilaudid) is recommended for pts w/ severe or multiple fractures - Common oral opioids for fracture pain include oxycodone , Percocet (oxycodone w/ acetaminophen) , and Norco (hydrocodone w/ acetaminophen)
- NSAIDs are given to decrease tissue inflammation but may slow
- As your muscles atrophy, the cast is expected to loosen.
- I will wrap a bandage around the cast to prevent it from slipping. - You need a new cast now that the swelling is decreased. ANS: D Often the surrounding soft tissues may be swollen considerably when the cast is initially applied. After the swelling has resolved, if the cast is loose enough to permit two or more fingers between the cast and the clients skin, the cast needs to be replaced. Elevating the arm will not solve the problem, and the clients muscles should not atrophy while in a cast for 6 weeks or less. An elastic bandage will not prevent slippage of the cast.
- A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury?
- Hypertension
- Constipation
- Infection - Hematuria ANS: D The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse should also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Constipation and infection are not complications of a pelvic fracture.
- A nurse cares for a client placed in skeletal traction. The client asks, what is the primary purpose of this type of traction? How should the nurse respond? - Skeletal traction will assist in realigning your fractured bone.
- This treatment will prevent future complications and back pain.
- Traction decreases muscle spasms that occur with a fracture.
- This type of traction minimizes damage as a result of fracture treatment. ANS: A Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.
- A nurse cares for a client in skeletal traction. The nurse notes that the skin around the clients pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?
- Request a prescription to decrease the traction weight.
- Apply an antibiotic ointment and a clean dressing.
- Cleanse the area, scrubbing off the crusty areas. - Obtain a prescription to culture the drainage. ANS: D These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately. The nurse should obtain a culture and assess
vital signs. The provider should be notified. By decreasing the traction weight, applying a new dressing, or cleansing the area, the infection cannot be significantly treated. A disadvantage of external fixation is an increased risk for pin-site infection. Pin-site infections can lead to osteomyelitis , which is serious and difficult to treat Osteomyelitis : inflammation of bone marrow, usually caused by infection in the long bones or spine
- A nurse cares for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication should the nurse administer first?
- Intravenous morphine
- Oral acetaminophen - Intravenous calcitonin
- O r a l i b u p r o f e n A N S : C The client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain (i.e., pain in the remaining portion of the limb). Oral acetaminophen and ibuprofen are not used in treating phantom limb pain. Calcitonin (Miacalcin) : a hormone produced by the thyroid gland that treats hypercalcemia and reduces bone pain. Calcitonin inhibits reabsorption of calcium from the bone and increases the storage of calcium in the bone. Calcitonin lowers circulating levels of calcium by promoting the excretion of calcium and phosphate by the kidneys
- Parathyroid Hormone (PTH) : hormone produced by the parathyroid glands that has the opposite effect of calcitonin (i.e. increase renal reabsorption of calcium, promotes release
- Cover any open areas with a dressing (preferably sterile)
- A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?
- Inability to maintain adduction of the affected arm for more than 30 seconds
- Shoulder pain that is relieved with overhead stretches and at night - Inability to initiate or maintain abduction of the affected arm at the shoulder
- Referred pain to the shoulder and arm opposite the affected shoulder ANS: C Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience referred pain to the opposite shoulder. Pain is usually more intense at night and with overhead activities. Rotator Cuff Injury :
- Drop Arm Test : when the arm is abducted, he or she usually drops it because abduction cannot be maintained
- Pain is more intense at night and with overhead activities
- Partial-thickness tears are more painful than full-thickness tears, but full-thickness tears result in more weakness and loss of function
- Muscle atrophy is commonly seen, and MOBILITY is reduced
- Diagnosis is confirmed with x-rays, MRI, ultrasonography, and/or CT scans.
- A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action?
- Pain of 4 on a scale of 0 to 10 - Numbness in the extremity
- Swollen extremity at the injury site
- F eel ing col d wh ile lyi ng in be d AN S: B The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an
expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.
- After teaching a client with a fractured humerus, the nurse assesses the clients understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture?
- Baked fish with orange juice and a vitamin D supplement
- Bacon, lettuce, and tomato sandwich with a vitamin B supplement
- Vegetable lasagna with a green salad and a vitamin A supplement - Roast beef with low-fat milk and a vitamin C supplement ANS: D The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation are appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.
- Calcium , phosphorus , vitamin D (regulates the absorption of calcium), and protein (needed to bind calcium for use by the body, 50% of calcium is protein bound) are necessary for the production of new bone
- Vitamin C and zinc are essential components in connective tissue repair
- Inadequate protein or insufficient vitamin C or D in the diet slows bone and tissue healing
- A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this clients pain?
- Meperidine (Demerol) injections every 4 hours around the clock - Patient-controlled analgesia (PCA) pump with morphine
- Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain
- Morphine 4 mg intravenous push every 2 hours PRN for pain ANS: B The older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control.
- A phone triage nurse speaks with a client who has an arm cast. The client states, My arm feels really tight and puffy. How should the nurse respond?
- Elevate your arm on two pillows and get ice to apply to the cast.
- Continue to take ibuprofen (Motrin) until the swelling subsides.
- This is normal. A new cast will often feel a little tight for the first few days. - Please come to the clinic today to have your arm checked by the
feel guilty by alluding to family members. The nurse should not refer to the client as being disabled as this labels the client and may fuel the clients poor body image.
- After teaching a client who is recovering from a vertebroplasty, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? - I can drive myself home after the procedure.
- I will monitor the puncture site for signs of infection.
- I can start walking tomorrow and increase my activity slowly.
- I will remove the dressing the day after discharge. ANS: A Before discharge, a client who has a vertebroplasty should be taught to avoid driving or operating machinery for the first 24 hours. The client should monitor the puncture site for signs of infection. Usual activities can resume slowly, including walking and slowly increasing activity over the next few days. The client should keep the dressing dry and remove it the next day. Surgical Procedures for VCF :
- Vertebroplasty : plastic surgical repair of a vertebra, typically with an injection of methyl methacrylate (“bone cement”)
- Kyphoplasty : treatment for a vertebral compression fracture (VCF) in which a collapsed vertebral body is restored to its normal size and shape with a balloon, followed by the injection of bone cement to maintain the bone's shape and strength Post-Op Care :
- Place supine for 1 to 2 hrs
- Neurologic assessment and monitor V/S frequently
- Apply ice to puncture site PRN to relieve pain
- Assess pain level and compare to pre-op pain level (give mild analgesic PRN)
- Monitor for complications (e.g., bleeding from puncture site, SOB, etc.)
- Assist with ambulation Discharge Instructions :
- Avoid driving or machinery for 24 hrs
- Monitor for signs of infection (e.g., erythema, pain, swelling, drainage)
- Keep dressing dry and remove the next day
- Begin usual activities (e.g., walking) the next day, and increase activity slowly over next few days
- A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the clients risk for infection?
- Wash the traction lines and sockets once a day.
- Release traction tension for 30 minutes twice a day.
- Do not place the traction weights on the floor.
- Schedule for pin care to be provided every shift. ANS: D To decrease the risk for infection in a client with skeletal traction of external fixation, the nurse should provide routine pin care and assess manifestations of infection at the pin sites every shift. The traction lines and sockets are external and do not come in contact with the clients skin; these do not need to be washed. Although traction weights should not be removed or released for any period of time without a prescription, or placed on the floor, this does not decrease the risk for infection. MULTIPLE RESPONSE
- A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client? (Select all that apply.) **- It leads to minimal blood loss.
- It allows for early ambulation.**
- It decreases the risk of infection.
- It increases blood supply to tissues. - It promotes healing. ANS: A, B, E External fixation is a system in which pins or wires are inserted through the skin and bone and then connected to a ridged external frame. With external fixation, blood loss is less than with internal fixation, but the risk for infection is much higher. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does not increase blood supply to the tissues. The nurse should assess for distal circulation, movement, and sensation, which can be disturbed by fracture injuries and treatments. Advantage (over other surgical interventions) :
- Minimal blood loss compared with internal fixation
- Allows for early ambulation and exercise of the affected body part while relieving pain
- Maintains alignment in closed fractures that will not maintain position in a cast
- Stabilizes comminuted fractures that require bone grafting
- Permits easy access to the wound in open fractures, while the bone heals Disadvantage :
- Increased risk for pin-site infection
- Pin-site infections can lead to osteomyelitis, which is serious and difficult to treat
- An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.)
- Temperature **- Urinary output
- Blood pressure**
- Pupil reaction - Skin color ANS: B, C, E
should teach the client to use the patient-controlled analgesia pump, but the nurse should never push the button for the client. Open Reduction w/ Internal Fixation (ORIF) :
- Open Reduction : the realignment of bone segments under direct visualization through an incision
- Internal Fixation : the use of metal pins, screws, rods, plates, or prostheses to immobilize the fracture during healing
- Common method of reducing and immobilizing a fracture
- Permits early mobility
- Allows surgeon to directly view the fracture site
- Contraindicated in active infections, fractures w/ multiple bone fragments, or in severe osteoporosis
- A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.) - Edema Increased capillary permeability
- Pallor Increased blood blow to the area **- Unequal pulses Increased production of lactic acid
- Cyanosis Anaerobic metabolism**
Tin glin g A rel eas e of hist am ine AN S: A, C, D Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, release of histamine, decreased tissue perfusion, and vasodilation. Unequal pulses are caused by an increased production of lactic acid. Cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, and tingling is caused by increased tissue pressure. PHYSIOLOGIC CHANGE
CLINICAL
FINDINGS
Increased compartment pressure No change Increased Edema
capillary permeability Release of histamine Increased edema Increased blood flow to area Pulses present & Pink tissue Pressure on nerve endings Pain Increased tissue pressure Referred pain to compartment Decreased tissue perfusion Increased edema Decreased oxygen to tissues Pallor Increased production of lactic acid Unequal pulses & Flexed posture Anaerobic metabolism Cyanosis Vasodilation Increased edema Increased blood flow Tense muscle swelling Increased tissue pressure Tingling & Numbness Increased edema Paresthesia Muscle ischemia Severe pain unrelieved by drugs Tissue necrosis Paresis/paralysis
- A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this clients teaching? (Select all that apply.) **- Frequently assess the ergonomics of the equipment being used.
- Take breaks to stretch fingers and wrists during working hours.**
- Do not participate in activities that require repetitive actions.
- Take ibuprofen (Motrin) to decrease pain and swelling in wrists. - Adjust chair height to allow for good posture. ANS: A, B, E Health promotion activities to prevent carpal tunnel syndrome include assessing the ergonomics of the equipment being used, taking breaks to stretch fingers and wrists during working hours, and adjusting chair height to allow for good posture. The client should be allowed to participate in activities that require repetitive actions as long as precautions are taken to promote health. Pain medications are not part of health promotion activities. Carpal tunnel syndrome (CTS) : a common condition in which the median nerve in the wrist becomes compressed, causing pain and
r A N S : C Some occupations, sports, and tasks can create repetitive motion injuries or cumulative trauma. A computer keyboard operator is an occupation with a high incidence of overuse syndrome.
- A client who plays baseball on the weekends is experiencing an arm injury. The nurse realizes this client needs to be evaluated for: - a rotator cuff tear. - lateral epicondylitis. - dislocation of the shoulder. - p atel lar ten din opa thy. AN S: A A rotator cuff tear can be caused by extensive overhead movements found in sports and activities such baseball, softball, tennis, swimming, and volleyball. A dislocation of the shoulder is most commonly caused by a fall on an outstretched hand and arm. Lateral epicondylitis, or tennis elbow, is an overuse injury that involves the extensor/supinator muscles that attach to the distal humerus. Patellar tendinopathy, also known as jumper’s knee, is seen in athletes who participate in activities that require a lot of jumping such as basketball. Jump er’s Knee = Patell ar Tendi nopat hy Tennis Elbow = Latera l Epico ndyliti s
- A client, diagnosed with an ankle sprain, is prescribed ibuprofen to control pain and inflammation. What instruction should the client receive concerning this medication?
- “Bleeding is not a problem with this medication.”
- “Take on an empty stomach to maximize its effect.” - “Take with food to minimize gastrointestinal irritation.”
- “Wear sunscreen if outside to prevent a burn.” ANS: C Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs should be taken with food to minimize gastrointestinal irritation. Ibuprofen does not increase photosensitivity; however, bleeding can be a problem when taking ibuprofen.
- A client, experiencing a fractured arm, asks the nurse why the splint is being applied. Which of the following should the nurse respond to this client? - “It reduces the need for a cast.” - “It reduces bleeding, swelling and pain.” - “It prevents the need for surgery.” - “It immobilizes the muscles and joints.” ANS: B Splinting of a fractured extremity minimizes bleeding, edema, and pain. Splinting does not reduce the need for a cast nor prevent the need for surgery. A cast immobilizes the muscles and joints.
- A client has had a cast applied to immobilize a right ulnar fracture. Which of the following nursing interventions is most important? - Calling physical therapy for a sling - Checking capillary refill time - Giving pain medication - S tartin g disch arge teachi ng ANS: B Checking the capillary refill time determines that circulation is not compromised. The other options can be completed after ensuring that circulation to the site is still adequate.
- A client with a right arm cast is experiencing signs of a serious complication. Which of the following would cause the nurse the most concern?
