Chapter 27: Management of Clients with Musculoskeletal Trauma or Overuse Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 27: Management of Clients with Musculoskeletal Trauma or Overuse

MULTIPLE CHOICE

1. A client is admitted to the emergency department with a complete fracture of the left radius. The nurse understands that with this type of fracture, the bone is

a.

displaced with fragments out of normal position.

b.

fractured only through one cortex of bone.

c.

fractured through the entire bone.

d.

fragmented with multiple pieces of bone.

ANS: C

In a complete fracture, the fracture line extends across the entire bone. Option a is a displaced fracture; option b is an incomplete fracture; and option d is a burst fracture.

DIF: Knowledge/Remembering REF: pp. 511-512 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. The initial process of bone healing occurring at the fracture site in the first 72 hours is

a.

formation of a hematoma.

b.

formation of a provisional callus.

c.

proliferation of osteoblasts.

d.

reabsorption of the clot.

ANS: A

Immediate formation of a hematoma at a fracture site occurs in 1 to 3 days.

DIF: Knowledge/Remembering REF: p. 509 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

3. A client with a left lower leg fracture in a cast for 3 days complains to the nurse that the pain medication does not relieve the pain any more. The priority action by the nurse would be to

a.

administer more analgesics.

b.

do a neurovascular assessment.

c.

elevate the cast on pillows.

d.

notify the physician.

ANS: B

Unrelieved pain is a manifestation of compartment syndrome, which is a serious complication of fractures. Other manifestations include pain out of proportion to the injury and escalating pain. If unrecognized or untreated, the client can lose nerve and muscle function. Amputation may be necessary. The nurse should perform a complete neurovascular assessment and notify the physician.

DIF: Application/Applying REF: p. 522 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

4. Two days after an accident in which a client sustained multiple injuries, including fractures, the client becomes confused and dyspneic and has a fever of 103.4 F. The nurse assesses that the client has developed

a.

a fat embolism.

b.

a pulmonary embolism.

c.

compartment syndrome.

d.

wound infection.

ANS: A

Manifestations of confusion, hypoxia, and fever may indicate a fat embolism in a client with multiple fractures.

DIF: Analysis/Analyzing REF: p. 522 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

5. The nurse explains to a client with delayed union of a fractured femur that treatment for this complication is based on

a.

finding and correcting the cause.

b.

physical therapy using deep-heat modalities.

c.

realigning the fracture with traction.

d.

stabilizing the fracture with a metal plate.

ANS: A

If the cause of the delayed union can be identified and corrected, the fracture usually heals.

DIF: Comprehension/Understanding REF: p. 518 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

6. In the emergent care of a client with a pelvic fracture, the nurse must be especially alert for indications of the complication of

a.

deep vein thrombosis.

b.

hyperthermia.

c.

hypovolemic shock.

d.

infection.

ANS: A

Pelvic fractures can result in hemorrhage into the pelvic cavity. The pelvic cavity can hold as much as 4 liters of blood.

DIF: Application/Applying REF: pp. 533-534 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

7. The nurse explains to the client that in addition to approximating the bone fragments, traction also

a.

increases blood supply to the fracture site.

b.

increases speed of bone healing.

c.

reduces muscle spasm.

d.

reduces neuromuscular dysfunction.

ANS: C

The purpose of traction is to realign the fracture and decrease muscle spasm. It does not increase blood supply, speed healing, or reduce neuromuscular dysfunction.

DIF: Comprehension/Understanding REF: p. 514 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

8. An elderly client is in the emergency department after suffering a fracture. The daughter is distraught and says This will never heal in my mother; shes so old! The most appropriate response by the nurse is

a.

Actually fractures in infants take the longest to heal.

b.

Do you think your mother has a bone disease, like osteoporosis?

c.

Unless there are other problems, elderly bones heal as quickly as in adults.

d.

Youre right; fractures take longer to heal in the elderly.

ANS: C

A fracture in an infant may heal in only 4-6 weeks, but the time increases somewhat with age. However, fractures in the elderly heal at the same speed as in other adults, unless a disease like osteoporosis is present. Other favorable and unfavorable factors that affect bone healing are summarized in Box 27-1.

DIF: Comprehension/Understanding REF: p. 508 OBJ: Intervention

MSC: Health Promotion and Maintenance Growth and Development Through the Lifespan-Age Related Differences

9. The nurse assesses an 85-year-old client who has fallen and finds crepitus and swelling below the right elbow. The nurse interprets these findings as

a.

a closed fracture.

b.

a dislocation.

c.

manifestations of degenerative joint disease.

d.

normal variations related to age.

ANS: A

Crepitus and swelling are caused by motion in the middle of a bone or by bone fragments rubbing together.

DIF: Application/Applying REF: p. 508 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

10. A client is considering running as an exercise. The nurse counsels that to prevent injuries, it is important before running to

a.

consume a large amount of carbohydrates, such as cereal or pasta.

b.

do 30 minutes of isometric leg exercises using weights.

c.

engage in a series of stretching and relaxing movements.

d.

perform static stretching exercises for 10 minutes.

ANS: D

Static stretching involves holding muscles in a stretched position for a few moments rather than repeatedly stretching and relaxing them. This is important to do before exercise requiring joint flexibility in order to prevent injury.

DIF: Application/Applying REF: p. 539 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Health and Wellness

11. The nursing intervention that would be most appropriate for a client who has entered the emergency department with a severe strain to the knee is

a.

apply a heat pack to reduce swelling.

b.

elevate the leg and apply ice.

c.

manipulate the knee in the full range of motion.

d.

teach the client exercises to speed healing.

ANS: B

Acute sprains require RICE: rest, ice, compression, and elevation for the first 24-48 hours to reduce swelling. Heat may be used after that if desired. During healing, which takes 4-6 weeks, movement of the injured part should be minimized.

DIF: Application/Applying REF: pp. 540-541 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

12. A client with long-standing dementia is sent to the emergency department from the nursing home in which the client resides. The report from the nursing staff states that the client is complaining of vague pain in the buttocks but seems to be ambulating without problems. The family requested the transfer. The emergency department nurse would suspect

a.

an overprotective family.

b.

arthritis pain the client cannot articulate.

c.

possible hip fracture.

d.

worsening dementia.

ANS: C

Some clients with hip fractures have normal ambulation and complain only of vague pain in their buttocks, knees, thighs, groin, or back, especially if they also have dementia. Since hip fractures are one of the leading causes of morbidity and mortality in the elderly, the nurse must maintain a high index of suspicion for fractures, especially in a client who has dementia.

DIF: Application/Applying REF: p. 527 OBJ: Assessment

MSC: Health Promotion and Maintenance Growth and Development Through the Lifespan-Age Related Differences

13. The nurse explains that the rationale for LMW (low-molecular-weight) heparin therapy after open reduction of a fractured femur is to

a.

decrease hematoma at the fracture site.

b.

decreases the threat of thrombus.

c.

increase blood supply at the fracture site.

d.

increase platelet formation.

ANS: B

Prevention of DVT is a primary goal for the client after ORIF. Pharmacologic agents such as LMW heparin or warfarin are used to prevent DVT.

DIF: Comprehension/Understanding REF: p. 528 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

14. In the application of a plaster cast, the most appropriate nursing intervention is to

a.

allow excess casting material to dry on the skin before removal.

b.

carefully cut the stockinette to the exact length of the cast.

c.

gently support the extremity from underneath.

d.

flush plaster-laden water down the toilet rather than the sink.

ANS: C

The nurse assisting during a cast application should support the extremity from underneath using only the palms of the hands to avoid applying pressure to any one area. The nurse should ensure he/she does not press fingertips into the cast or allow it to rest on a hard surface because this can lead to indentations in the cast that can ultimately cause pressure and injury to the client. The stockinette is cut several inches longer than the anticipated cast. As soon as the cast is applied, excess plaster needs to be removed from the clients skin. The water used to wet the plaster should be dumped down a sink with a plaster trap. If no such sink is available, the water should be allowed to sit until the plaster settles at the bottom of the bucket; then the water can be drained off the top and the plaster scooped out into a trash bag.

DIF: Application/Applying REF: p. 519 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

15. After application of a synthetic cast, the client asks the nurse how long he must wait until the cast is completely dry and he can tolerate weight-bearing. The nurses most appropriate response is

a.

10 minutes.

b.

20 minutes.

c.

30 minutes.

d.

60 minutes.

ANS: C

Synthetic casts are dry to the touch in a few minutes but require about 30 minutes to set and allow weight-bearing.

DIF: Comprehension/Understanding REF: pp. 519-520 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

16. The nurse informs a client that her plaster cast is dry because the nurse has assessed that the cast is

a.

cold to the touch.

b.

dull on percussion.

c.

gray in color.

d.

odorless.

ANS: D

A dry plaster cast is odorless, resonant, white, and feels close to room temperature.

DIF: Comprehension/Understanding REF: pp. 520-521 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

17. When a 68-year-old client with a new full-leg cast exhibits bilateral pedal edema, the nurse would assess for

a.

compartment syndrome.

b.

cardiovascular disease.

c.

local leg trauma.

d.

thrombophlebitis.

ANS: B

Swelling after traumatic injury and reduction should peak within 24-48 hours, but mild swelling afterwards is expected. Moderate or severe swelling and discoloration are abnormal. With abnormal unilateral pedal edema, the nurse should consider whether it is caused by further trauma, by compartment syndrome, or by thrombophlebitis. With bilateral pedal edema, the nurse should consider a cardiovascular origin.

DIF: Analysis/Analyzing REF: p. 522 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Illness Management

18. After the cast on a clients fractured ulna has been changed to a bivalve cast, the nurse will alter the approach to care by

a.

omitting vascular checks to the extremity.

b.

preventing pinching the extremity between the two halves.

c.

taking off both halves of the cast when x-ray films are ordered.

d.

taping the halves together with paper tape.

ANS: B

The bivalve cast allows for removal of the top half for wound care or x-ray films and for ease in assessing tissue perfusion or pressure areas. When the top half is reapplied, the nurse must take precaution not to pinch the clients extremity between the two halves as they are secured together with an Ace wrap.

DIF: Application/Applying REF: p. 521 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

19. The assessment that would alert the nurse to the possibility of cast syndrome in a client with a spica cast is

a.

abdominal distention.

b.

diminished pulses in the foot.

c.

hot spot felt on cast.

d.

musty, unpleasant odor to cast.

ANS: A

Abdominal distention and persistent vomiting result when the duodenum is compressed between major vessels and vertebral bodies because of constriction on the spica cast.

DIF: Application/Applying REF: p. 523 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

20. In caring for a client in skeletal traction with a nursing diagnosis of Risk for Injury related to traction, the nurse should take special care to

a.

carefully inspect pin sites every other day to assess for pin site infection.

b.

encourage the client to assume a position of comfort to reduce the risk of pressure ulcers.

c.

knot ropes between the client and pulley to prevent weights from touching the floor.

d.

position weight ropes to ensure that the weights hang freely from pulleys.

ANS: D

The weights must hang freely to ensure traction. Knotting the ropes between the client and the pulley causes distraction. The client must be kept in anatomic alignment to prevent poor union. Pin sites should be checked more often than every other day.

DIF: Application/Applying REF: p. 525 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

21. The nurse assesses a client in the emergency department who complains of shoulder pain and is unable to abduct or externally rotate the right arm. From these observations the nurse suspects injury to the

a.

anterior cruciate ligament.

b.

meniscus.

c.

tendonitis.

d.

rotator cuff.

ANS: D

A torn rotator cuff prevents the client from abducting or externally rotating the affected arm. The anterior cruciate ligament is in the knee. Meniscus injury is also a knee problem.

DIF: Application/Applying REF: pp. 537-538 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

22. The principal concept that a nurse would include in a teaching plan regarding partial weight-bearing is that the client should

a.

bear as much weight as can be tolerated 30% to 50% of the time.

b.

prevent the affected limb from touching the floor; bear weight on the unaffected limb.

c.

rest the affected foot on the floor and place weight on it 30% to 50% of the time.

d.

use a walker or crutches and bear 30% to 50% of weight on the affected limb.

ANS: C

Partial weight-bearing allows the client to bear 30% to 50% of weight on the affected limb.

DIF: Comprehension/Understanding REF: p. 531 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

23. A client who has undergone repair of the anterior cruciate ligament complains that the use of the continuous passive motion (CPM) machine causes pain and asks how long he is expected to use the machine. The nurses most appropriate response would be

a.

I will give you pain medication to make you comfortable, since you should use the machine at least 8 hours out of 24.

b.

Try using the machine for 1 hour of every 4 hours, and see if that schedule reduces your discomfort.

c.

You do not have to use the machine for the next few days. You can resume after the pain subsides.

d.

You should use the machine continuously. I will ask the physician to increase your dose of analgesics.

ANS: A

The CPM machine should be used at least 8 hours a day or until full range of motion is achieved.

DIF: Application/Applying REF: p. 538 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

24. Important self-care measures the nurse should teach to the client who is expected to be immobile in a wheelchair for a lengthy period of time include

a.

learning how to inspect all skin surfaces for friction or pressure.

b.

massaging bony prominences four times a day.

c.

sitting upright in a chair or wheelchair on the sacrum.

d.

using a gel wheelchair cushion to prevent pressure ulcers.

ANS: A

Clients, especially those with paraplegia and decreased sensation, need to learn to inspect all body surfaces for pressure or friction injuries, using a long-handled mirror if necessary. Clients should not massage bony prominences because this leaves them soft and vulnerable to pressure or shear. Clients should sit upright on their buttocks. Gel cushions should be avoided because they are expensive and heavy, they tend to break down, and they make moving the wheelchair more difficult.

DIF: Comprehension/Understanding REF: p. 534 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

25. A victim of a motorcycle accident has an open fracture of the left femur with an associated wound of 8 cm. The nurses assessment records this injury as grade

a.

I.

b.

II.

c.

III.

d.

IV.

ANS: C

A grade III wound is 6 to 8 cm in length with accompanying extensive tissue damage and high degree of contamination. A grade I is smaller than 1 cm with minimal contamination. A grade II wound is larger than 1 cm with moderate contamination. The classification system stops at grade III.

DIF: Application/Applying REF: p. 510 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

26. The nurse notices a stain on a newly dried plaster cast over a clients fracture site. The most appropriate method to assess this finding is to

a.

assess for a hot spot over the stain.

b.

bivalve the cast and inspect the site.

c.

draw around the circumference with a pen and record.

d.

dry the stained area of the cast with a hair dryer.

ANS: C

A stain indicates wound drainage and should be carefully measured and documented. Drawing on the cast around the stain gives a baseline against which to compare extension of the stain.

DIF: Application/Applying REF: p. 522 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

27. The complaint of proximal thigh pain in an older client who has fallen leads the nurse to suspect a hip fracture and that the location of the fracture is

a.

intracapsular.

b.

intratrochanteric.

c.

subtrochanteric.

d.

the femoral neck.

ANS: C

Subtrochanteric fractures typically produce pain over the proximal thigh. Groin pain is associated with a femoral neck fracture and pain over the trochanter with an intratrochanteric fracture.

DIF: Application/Applying REF: pp. 526-527 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

28. The nurse in the emergency department caring for a client with an anterior dislocation of the knee should have as a priority the assessment of

a.

capillary refill of the toes.

b.

degree of misalignment in the limb.

c.

degree of pain in the joint.

d.

mobility in the affected limb.

ANS: A

Anterior dislocation of the knee is a medical emergency. Neurovascular status must be assessed carefully because displaced bone may tear vessels, impede circulation, and damage nerves. While all assessments above are pertinent, neurovascular status takes priority.

DIF: Application/Applying REF: p. 537 OBJ: Assessment

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

MULTIPLE RESPONSE

1. When delegating the application of heat or cold therapies to an unlicensed assistive personnel (UAP), the nurse should (Select all that apply)

a.

allow the UAP to document the treatment and the clients response.

b.

clarify the order to ensure the task can be delegated.

c.

inspect the clients skin before the treatment.

d.

instruct the UAP to wrap the heat or cold in a protective cover.

e.

reassess the clients skin after the treatment is done.

ANS: B, C, D, E

The nurse is responsible for assessments before and after the treatment and for documenting the clients response to a treatment. The nurse should also ensure that the task is appropriate for delegation. For further information, see the Management and Delegation feature.

DIF: Analysis/Analyzing REF: p. 530 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Delegation

2. A nurse is teaching a community group about bone health. Which of the following does the nurse recommend? (Select all that apply.)

a.

Engage in regular weight-bearing exercise.

b.

Get plenty of calcium and vitamin D in the diet.

c.

If diagnosed with osteoporosis, take medications as prescribed.

d.

Stop, or do not start, smoking.

e.

Swim or cycle to get aerobic activity without stressing joints.

ANS: A, B, C, D

All four options are good for bone health. Option e provides muscle-strengthening exercises that may help prevent falls, but does not improve actual bone health.

DIF: Comprehension/Understanding REF: p. 533 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

3. A client who will not regain mobility has a case manager. What important topics does the nurse need to address in the clients long-term plan of care? (Select all that apply.)

a.

Informal caregivers

b.

Sexuality

c.

Recreation

d.

Vocational adjustments

ANS: A, B, C, D

The client who will not regain mobility must make many choices regarding a lifestyle that has been changed dramatically. All topics are important, but sexuality is often overlooked. Sexuality, recreation, and vocation are important components of quality of life. Informal caregivers can fill the gap between formal, provided services and client need.

DIF: Application/Applying REF: p. 534 OBJ: Intervention

MSC: Psychosocial Integrity Psychosocial Adaptation-Quality of Life

4. A nurse planning discharge teaching and counseling for the client being dismissed with multiple fractures plans support services knowing that fractures can disrupt quality of life by causing (Select all that apply)

a.

activity restrictions.

b.

disability.

c.

economic loss.

d.

pain and suffering.

ANS: A, B, C, D

Fractures can cause impaired quality of life by affecting all the above. While many people can completely recover from a fracture, some clients, especially the elderly, find their independence threatened and some may no longer be able to live alone.

DIF: Application/Applying REF: p. 507 OBJ: Intervention

MSC: Psychosocial Integrity Psychosocial Adaptation-Quality of Life

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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