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A client arrives in the emergency department complaining of severe pain in the left hip after falling out of the bed. What indication(s) upon assessment does the nurse recognize as a dislocated left hip?
- A. The left leg appears shorter
- B. The skin is warm to the touch
- C. Limited range of motion of the left hip
- D. Swelling around the hip
- E. The skin of the lower left leg is pale
- F. The client is able to bend the knee but not move toes
Correct Answer: A,C,D
Rationale: The leg may be shorter than its unaffected counterpart as a result of the displacement of one of the articulating bones. Range of motion is limited. Evidence of soft tissue injury includes swelling, coolness, numbness, tingling, and pale or dusky color. The client will not be able to bend the knee easily, and toe movement is typically preserved unless there is nerve damage.
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A client is diagnosed with a first-degree strain of the left ankle related to running 5 miles daily. How would the nurse differentiate the first-degree strain from other strains and sprains?
- A. The client has some edema of the left ankle with muscle spasms but is able to walk without assistive devices.
- B. The client is unable to bear weight on the left ankle and has a large ecchymotic area.
- C. The client has ecchymosis, edema, and has no function of the left foot and ankle.
- D. The client complains of pain when the joint is moved and has mild edema.
Correct Answer: A
Rationale: A first-degree strain involves mild stretching of the muscle or tendon, causing some edema and muscle spasm, but no real loss of function. The second-degree strain is partial tearing of muscle or tendon, leading to inability to bear weight and causing edema, muscle tenderness, muscle spasm, and ecchymosis. The third-degree tear is severe muscle and/or tendon tearing, causing severe pain, muscle/spasm ecchymosis, edema, and loss of function. A first-degree sprain involves stretching of the ligament fibers characterized by mild edema, tenderness, and pain if the joint is moved.
A client with metastatic bone cancer sustained a left hip fracture without injury. What type of fracture does the nurse understand occurs without trauma or fall?
- A. Impacted fracture
- B. Transverse fracture
- C. Compound fracture
- D. Pathologic fracture
Correct Answer: D
Rationale: A pathologic fracture is a fracture that occurs through an area of diseased bone and can occur without trauma or a fall. An impacted fracture is a fracture in which a bone fragment is driven into another bone fragment. A transverse fracture is a fracture straight across the bone. A compound fracture is a fracture in which damage also involves the skin or mucous membranes.
A client suffered a subtrochanteric hip fracture after falling out of the bed. What complication should the nurse monitor closely for related to this type of fracture?
- A. Pulmonary edema
- B. Abdominal pain
- C. Urinary retention
- D. Hypovolemia
Correct Answer: D
Rationale: Subtrochanteric hip fractures can lead to significant blood loss into the surrounding tissues, increasing the risk of hypovolemia. The nurse should monitor for signs of hypovolemia, such as tachycardia, hypotension, and decreased urine output.
A client has been prescribed nonsteroidal anti-inflammatory medications for treatment of carpal tunnel syndrome. What should the nurse be sure to include when educating the client about taking this medication?
- A. Take the medication on an empty stomach to assist in faster absorption.
- B. Take the medication with food.
- C. The medication may cause drowsiness, so do not operate machinery or drive a vehicle.
- D. The dosage may be exceeded if pain is not relieved by the prescribed dose.
Correct Answer: B
Rationale: If the client is taking NSAIDs, the nurse stresses to take these medications with food. The most common adverse effects of NSAIDs are related to the gastrointestinal tract. The medication should not be taken on an empty stomach and taking it that way does not cause more rapid absorption. The medication does not generally cause drowsiness, and the dosage should never be exceeded.
A client comes to the emergency department and it is found that the client's radial head is partially dislocated. What is this partially dislocated radial head documented as?
- A. Volkmann's contracture
- B. Subluxation
- C. Compartment syndrome
- D. Sprain
Correct Answer: B
Rationale: A partial dislocation is referred to as a subluxation. A Volkmann contracture is a claw-like deformity that results from compartment syndrome or obstructed arterial blood flow to the forearm and hand. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space and affects nerve innervation, leading to subsequent palsy. A sprain is injury to the ligaments surrounding the joint.