Chapter 54: Care of Patients with Musculoskeletal Trauma Nursing School Test Banks

Chapter 54: Care of Patients with Musculoskeletal Trauma

Test Bank

MULTIPLE CHOICE

1. A client has a fracture and is being treated with skeletal traction. Which assessment causes the nurse to take immediate action?

a.

The clients blood pressure is 130/86 mm Hg.

b.

The traction weights are resting on the floor.

c.

Slight oozing of clear fluid is noted at the pin site.

d.

Capillary refill of the extremity is less than 3 seconds.

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. Slight oozing of clear fluid is normal as is the capillary refill time. 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

2. A client has been diagnosed with carpal tunnel syndrome. Which intervention does the nurse question in the treatment of this injury?

a.

Ibuprofen 600 mg three times a day with meals

b.

Weekly injections of a corticosteroid by the physician

c.

Morphine 30 mg to be taken orally every 4 hours

d.

Use of a hand brace or splint during the day

ANS: C

The client with carpal tunnel syndrome can be treated nonsurgically by administration of oral NSAIDs and corticosteroid injections. Most clients find relief with taking these medications and the use of a hand brace or splint to immobilize the wrist. The use of opioids such as morphine should not be necessary. NSAIDs and corticosteroids decrease inflammation and pain.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

3. The nurse is caring for a client with a fractured femur. Which factor in the clients history may impede healing of the fracture?

a.

A sedentary lifestyle

b.

A history of smoking

c.

Oral contraceptive use

d.

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.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1148

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

4. A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurses first intervention?

a.

Assess pedal pulses.

b.

Apply oxygen by nasal cannula.

c.

Increase the IV flow rate.

d.

Document the finding.

ANS: A

The symptoms represent early warning of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

5. While assessing an older adult client admitted 2 days ago with a fractured hip, the nurse notes that the client is confused, tachypneic, and restless. Which is the nurses first action?

a.

Administer oxygen via nasal cannula.

b.

Apply restraints and ask for a sitter.

c.

Slow the IV flow rate.

d.

Discontinue the pain medication.

ANS: A

The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Pain medication most likely would not cause the client to be restless. The IV rate is not related.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

6. The nurse is caring for several clients with fractures. Which client does the nurse consider at highest risk for developing deep vein thrombosis?

a.

Middle-aged woman with a fractured ankle taking aspirin for rheumatoid arthritis

b.

Young adult male athlete with a fractured clavicle

c.

Female with type 2 diabetes with fractured ribs

d.

Older 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, and heart disease. The other clients do not have risk factors for DVT.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

7. The nurse is rounding on assigned orthopedic clients. The client with which type of fracture requires immediate interventions to prevent infection?

a.

Fractured clavicle

b.

Open fracture of the tibia

c.

Simple fracture of the wrist

d.

Compression fracture of a vertebra

ANS: B

Bone infection or osteomyelitis is most common in clients with an open fracture because skin integrity is lost and organisms gain access easily. The nurse will remind all those who come into contact with the client to use good handwashing and will observe the wound daily for signs of infection. The other clients do not have extra risk factors for infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

8. The nurse is performing an assessment on a client admitted with a fractured left humerus. When the client moves the extremity, the nurse notes the presence of a grating sound. Which is the nurses best intervention?

a.

Immobilize the arm.

b.

Perform range of motion.

c.

Monitor for other signs of infection.

d.

Administer steroids.

ANS: A

The 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 him or her not to move the arm. The nurse should not move the extremity for range of motion. The grating sound does not indicate infection. Steroids would not be indicated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Analysis)

9. The nurse is caring for a client with a pelvic fracture. Which is the nurses priority action to prevent complications?

a.

Monitor temperature daily.

b.

Insert a urethral catheter.

c.

Monitor blood pressure frequently.

d.

Turn the client every 2 hours.

ANS: C

With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the clients vital signs, skin color, and level of consciousness frequently to determine whether shock is occurring. The client may need a urethral catheter inserted at some point in time if voiding is a problem. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. The client should not be turned on his or her side unless the fracture is stabilized.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

10. A client who had a plaster cast applied to the right arm 3 weeks ago presents to the clinic with an erythrocyte sedimentation rate (ESR) that has increased from 15 to 25 mm/hr. Which is the nurses best action?

a.

Repeat this laboratory assessment in 4 hours.

b.

Have the cast reapplied.

c.

Evaluate temperature and vital signs.

d.

Obtain blood for a platelet count.

ANS: C

A rise in the ESR during fracture healing suggests a bone infection or a fat embolism. The nurse should collect all other assessment data that can assist in confirming this diagnosis and then should notify the health care provider. Repeating the laboratory assessment, reapplying the cast, and assessing a platelet count would not be indicated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation)

11. The home care nurse is visiting a client with diabetes who has a new cast on the arm. On assessment, the nurse finds the clients fingers to be pale, cool, and slightly swollen. Which is the nurses first intervention?

a.

Elevate the arm above the level of the heart.

b.

Encourage active and passive range of motion.

c.

Apply heat to the affected hand.

d.

Place a window or bivalve the cast.

ANS: A

Arm casts can impinge on circulation when the arm is in the dependent position. The nurse should immediately elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and should reassess the extremity in 15 minutes. If the fingers are warmer and less swollen, the cast is not too tight and adjustments do not need to be made, but a sling should be worn when the client is upright. Heat would cause increased edema and should not be used. Encouraging range of motion would not assist the client as much as elevating the arm. If the cast is assessed to be too tight, it could be bivalved.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications of Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

12. A client who had a wrist cast applied 3 days ago calls from home, reporting that the cast is loose enough to slide off. How does the nurse respond?

a.

Keep your arm above the level of your heart.

b.

As your muscles atrophy, the cast is expected to loosen.

c.

Wrap an elastic bandage around the cast to prevent it from slipping.

d.

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.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1153

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

13. The nurse is assessing a client with a body cast. Which assessment finding indicates a complication that must be reported to the health care provider?

a.

Blood pressure, 130/85 mm Hg

b.

Urinary output, 40 mL/hr

c.

Redness around the edges of the cast

d.

Vomiting after meals

ANS: D

The client in a body cast is monitored for cast syndrome, which results in intestinal obstruction. Vomiting after meals may indicate that this is occurring. Bowel sounds might be normal with this condition. The rest of the assessments are not related to cast syndrome.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications of Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

14. A client for whom skeletal traction is planned asks for an explanation regarding the purpose of this type of traction. Which is the nurses best response?

a.

It aids in realigning the bone.

b.

It prevents low back pain.

c.

It decreases muscle spasms that occur with a fracture.

d.

It prevents injury to the skin as a result of the fracture.

ANS: A

Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. The other choices are not primary purposes of skeletal traction.

DIF: Cognitive Level: Comprehension/Understanding REF: pp. 1153-1154

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Communication and Documentation

15. The nurse notes that the skin around the clients skeletal traction pin site is swollen, red, and crusty, with dried drainage. Which is the nurses priority intervention?

a.

Decrease the traction weight.

b.

Apply a new dressing.

c.

Cleanse the area, scrubbing off the crusty areas.

d.

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

16. The nurse is caring for a client with an external fixator in place on the leg. What does the nurse assess for first?

a.

Alteration in skin integrity

b.

Impaired motor action

c.

Acute pain

d.

Signs of infection

ANS: D

As long as the external fixator is in place, a direct connection is present between the external environment and the bone. The risk for infection is high. An expected alteration in skin integrity and a decrease in movement are noted. Acute pain would not be expected, but the client should be medicated for pain if necessary.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

17. The nurse is teaching a client who has left leg weakness to walk with a cane. Which gait training technique is correct?

a.

Place the cane in the clients left hand and move the cane forward, followed by moving the left leg one step forward.

b.

Place the cane in the clients left hand and move the cane forward, followed by moving the right leg one step forward.

c.

Place the cane in the clients right hand and move the cane forward, followed by moving the left leg one step forward.

d.

Place the cane in the clients right hand and move the cane forward, followed by moving the right leg one step forward.

ANS: C

Placing the cane in the clients left hand does not provide sufficient stability. After the cane in the right hand (stronger side) is moved ahead, the cane and the stronger leg provide a stable base for movement of the weaker leg. The other techniques are not correct.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Implementation)

18. A client asks why a plaster cast is not applied to the fractured clavicle. Which is the nurses best response?

a.

Plaster will make the area too heavy for movement.

b.

A splint or a bandage is sufficient to keep the bones in alignment.

c.

Cloth braces are less likely to disrupt circulation.

d.

Fractures to the upper body always heal more quickly.

ANS: B

Because upper extremities do not bear weight, cloth splints are usually sufficient to immobilize the fracture. The other responses are not accurate for this type of fracture.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1151

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialTherapeutic Procedures) MSC: Integrated Process: Teaching/Learning

19. The nurse assesses a client with a below-knee amputation. Which assessment of the skin flap requires immediate action?

a.

Pink and warm to the touch

b.

Pale and cool to the touch

c.

Dark pink and dry to the touch

d.

Pink and slightly moist to the touch

ANS: B

The skin flap should appear pink in a light-skinned person and not discolored in a darker-skinned person. The area should feel warm but not hot. Pale and cool skin could indicate inadequate blood flow to the area. The nurse would notify the provider.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

20. A client who has had an above-knee amputation of the right leg reports pain in the right foot. Which priority medication does the nurse administer?

a.

IV morphine

b.

650 mg of acetaminophen

c.

IV calcitonin

d.

600 mg of ibuprofen

ANS: C

The client is experiencing phantom limb pain. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. The other medications will not assist in decreasing the clients pain.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesPharmacological Pain Management)

MSC: Integrated Process: Nursing Process (Implementation)

21. The nurse is caring for a client 3 days after a below-knee amputation. Which is a priority intervention?

a.

Muscle-strengthening exercises

b.

Use of a very soft bed mattress

c.

Placing a pillow between the clients knees

d.

Placing the client in high Fowlers position

ANS: A

To prepare for a prosthesis, the nurse instructs the client in muscle-strengthening exercises, provides the client with a firm mattress, and places the client in a prone position every 3 to 4 hours for 20 to 30 minutes to prevent flexion contractures. A pillow should not be placed between the clients knees.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

22. The nurse is caring for clients with above-knee amputations. Which client does the nurse treat first?

a.

Client who reports phantom limb pain

b.

Client who reports cramping

c.

Client who does not want to move the leg

d.

Client with regional pain syndrome

ANS: D

The first priority in the management of clients with complex regional pain syndrome is pain relief. Pain can be of prolonged duration and will require pharmacologic and nonpharmacologic modalities for control. If this client is not treated immediately, prolonged pain may be triggered. The client with phantom limb pain would be the next priority. The client who does not want to move and the client with cramping would be treated after the clients with pain.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

23. The nurse is caring for a client after arthroscopy surgery. Which intervention is a postoperative priority for this client?

a.

Passive range of motion on the involved knee

b.

Active range of motion on the involved knee

c.

Straight leg raises with the involved leg

d.

Immobilization of the leg

ANS: C

Straight leg raises and quadriceps setting are started immediately after the client awakens from the anesthesia. These exercises are performed to strengthen the leg, prevent venous thromboembolism, and decrease swelling. Bending the affected knee and range of motion should not be done for several days. Immobilization will lead to additional complications.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialTherapeutic Procedures) MSC: Integrated Process: Nursing Process (Implementation)

24. The client is being assessed for rotator cuff injury. Which physical assessment finding is consistent with this type of injury?

a.

The client is unable to maintain adduction of the affected arm at the shoulder for longer than 30 seconds.

b.

The client is able to raise the affected arm to shoulder height but feels pain on doing this maneuver.

c.

The client is unable to initiate or maintain abduction of the affected arm at the shoulder.

d.

The client has 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 other options are not descriptive of a rotator cuff injury.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1173

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

25. The nurse is caring for a client with a fractured fibula. Which assessment prompts immediate action by the nurse?

a.

Reported pain of 4 on a scale of 0 to 10

b.

Numbness and tingling in the extremity

c.

Swollen extremity where the injury occurred

d.

Reports of being cold in bed

ANS: B

The client with numbness and 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Planning)

26. A client has a fractured humerus. Which dietary choice indicates that the client understands the nutrition needed to assist in healing the fracture?

a.

Skim milk, vitamin D supplements, and fish

b.

Soy milk, vitamin B supplements, and bacon, lettuce, and tomato sandwich

c.

Whole milk, vitamin A supplements, and vegetable lasagna

d.

Low-fat milk, vitamin C supplements, and roast beef

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

27. The nurse is caring for an older adult client with multiple fractures. How does the nurse manage pain in this client?

a.

Meperidine (Demerol) injections every 4 hours rather than PRN

b.

Patient-controlled analgesia (PCA) pump with morphine

c.

Ibuprofen (Motrin) 600 mg every 4 hours

d.

IV morphine PRN

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesPharmacological Pain Management)

MSC: Integrated Process: Nursing Process (Implementation)

28. A client has an arm cast and reports that it feels really tight and the fingers are puffy. What is the nurses best response?

a.

Elevate your arm on two pillows and apply ice to the cast.

b.

Continue to take ibuprofen (Motrin) until the swelling subsides.

c.

It is normal for a new cast to feel a little tight for the first few days.

d.

Please come to the clinic today to have your arm checked by the health care provider.

ANS: D

Puffy fingers and a feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the provider because delay of treatment can cause permanent damage to the extremity. Ice and Motrin are acceptable actions, but checking the cast is the priority because it ensures client safety. The nurse should not just reassure the client that this is normal.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications of Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Analysis)

29. A client who had a long-leg cast applied last week reports to the clinic nurse, I cant seem to catch my breath and I feel a bit lightheaded. Which is the priority action of the nurse?

a.

Listen to the clients lungs and check the clients blood glucose level.

b.

Give the client 2 L of oxygen via nasal cannula and check vital signs.

c.

Check the clients pulse oximetry and arrange emergency transfer to the hospital.

d.

Reassure the client that it takes much more effort to move with a long-leg cast.

ANS: C

The clients symptoms are consistent with the development of pulmonary embolism (PE) caused by leg immobility in the long cast. The nurse should check the clients pulse oximetry reading and arrange for transfer to the hospital for further testing and treatment. The client should not be reassured that the symptoms are caused by exertion. The nurse can check vital signs, administer oxygen, and check the clients blood glucose level while waiting for transport to the emergency department.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

30. A client has left-sided weakness. Which action by the client indicates that additional teaching about proper cane use is needed?

a.

Holding the cane in the right hand

b.

Advancing the cane while the right leg moves forward

c.

Stepping forward first with the right leg when ambulating

d.

Flexing the elbow 15 to 20 degrees when holding the cane

ANS: B

The cane should be held on the strong right side so that it provides support for the weaker left side. The cane should be advanced with the opposite affected lower limb (the left leg for this client). The client should step forward with the strong right leg when ambulating. The elbow should be flexed 15 to 20 degrees when the client is holding the cane.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Teaching/Learning

31. The nurse is caring for an older adult client who had leg amputation surgery the previous day. During the admission assessment, the client tells the nurse, I dont want to live with only one leg, so I should have died during the surgery. Which is the nurses best response?

a.

Your vital signs are good, and you are doing just fine right now.

b.

Your children are waiting outside and do not want to lose their parent.

c.

Remember that you are still the same person inside, with a missing body part.

d.

You will be able to do some of the same things as before you became disabled.

ANS: C

The client feels like less of a person following the amputation, so the nurse should remind the client that he is still the same person inside. The nurse should not try to make the client feel guilty by saying that his children do not want to lose their parent. The nurse should not ignore the clients feelings by focusing on vital signs. The nurse should not refer to the client as being disabled.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)

MSC: Integrated Process: Caring

MULTIPLE RESPONSE

1. A client has a fractured tibia and is asking the nurse about external fixation. What are some advantages for the use of external fixation for the immobilization of fractures? (Select all that apply.)

a.

Leads to minimal blood loss

b.

Allows for early ambulation

c.

Decreases the risk of infection

d.

Increases blood supply to tissues

e.

Provides visualization of bone ends

f.

Promotes healing

ANS: A, B, F

Blood loss is less. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does place the client at risk for infection and does not increase the blood supply to tissues, nor does it provide visualization of the ends of the bone.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1155

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialTherapeutic Procedures) MSC: Integrated Process: Nursing Process (Analysis)

2. An older woman is admitted after falling down the stairs. Which assessment findings require immediate intervention? (Select all that apply.)

a.

Blood pressure, 80/50 mm Hg

b.

Potassium, 6.0 mEq/L

c.

Dark brown urine

d.

Heart rate, 90 beats/min

e.

Urine output, 50 mL/hr

ANS: A, B, C

Low blood pressure could indicate hypovolemia, which occurs with crush syndrome. Hyperkalemia and dark brown urine also may indicate crush syndrome. A heart rate of 90 beats/min is within normal limits; urine output of 50 mL/hr is also a normal finding.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Evaluation)

3. A client with a new fracture reports pain in the site of the fracture. An opioid pain medication was administered 20 minutes ago. Which is the nurses best intervention? (Select all that apply.)

a.

Administration of additional opioids

b.

Elevation of the extremity

c.

Application of ice

d.

Application of heat

e.

Keeping the extremity in a dependent position

ANS: A, B, C

The client with a new fracture likely has edema; elevating the extremity and applying ice probably will help in decreasing pain. Heat will increase edema and may increase pain. Dependent positioning will also increase edema. Administration of an additional opioid within the dosage guidelines may be ordered.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

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