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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.
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A client has sustained a left femur fracture in a skiing accident. When is the nurse aware that the complication of a fat emboli typically occurs and should be monitored for closely?
- A. The first hour after fracture of the long bone
- B. 8 to 12 hours
- C. 12 to 24 hours
- D. 48 to 72 hours
Correct Answer: D
Rationale: The client should be monitored for symptoms of a fat embolism, which typically occurs within 48 to 72 hours.
A client is admitted to the emergency department after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention?
- A. Compound
- B. Greenstick
- C. Oblique
- D. Spiral
Correct Answer: A
Rationale: A compound fracture is a fracture in which damage also involves the skin or mucous membranes with the risk of infection great. A greenstick fracture is where one side of the bone is broken and the other side is bent; it does not protrude through the skin. An oblique fracture occurs at an angle across the bone but does not protrude through the skin. A spiral fracture twists around the shaft of the bone but does not protrude through the skin.
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.
The nurse is demonstrating how to perform range-of-motion (ROM) exercises for a patient with tendinitis of the wrist. What intervention can the nurse encourage the client to use in order to decrease discomfort when performing the exercises?
- A. Perform the exercises when using hand weights.
- B. Perform the exercises and then take pain medication.
- C. Perform the exercises with the hand and wrist under warm water.
- D. Perform the exercises after icing the hand and wrist.
Correct Answer: C
Rationale: Some clients find that hand exercises are less painful if performed with the hand under warm water. Hand weights should not be used when performing exercises unless prescribed by the physician and will not decrease discomfort. Pain medication such as an NSAID should be taken prior to exercising. The use of ice is not recommended after 48 hours postinjury and may make the exercises more uncomfortable.
The nurse is assisting with an examination of a client suspected of having carpal tunnel syndrome. The physician has the client flex the wrist for 30 seconds and percusses the median nerve. The client complains of pain and numbness when this is done. What does the nurse know this positive sign is documented as?
- A. Tinel sign
- B. Phalen sign
- C. Crepitus
- D. Spasm
Correct Answer: B
Rationale: Phalen sign involves having the client flex the wrist for 30 seconds to determine if pain or numbness occurs (a positive sign for carpal tunnel syndrome). The examiner percusses the median nerve, located on the inner aspect of the wrist, to elicit this response. Tinel sign is also a test that elicits pain and numbness in clients with carpal tunnel syndrome and occurs by lightly tapping the median nerve. Crepitus is a grating sound that is elicited when two bones rub together. Spasm is not indicative of carpal tunnel syndrome.