Nokea
A client sustains a fractured right humerus in an automobile accident. The arm is edematous, the client reports not being able to feel or move the fingers, and the nurse does not feel a pulse. What condition should the nurse be concerned about that requires emergency measures?
- A. Compartment syndrome
- B. Dislocation
- C. Muscle spasms
- D. Subluxation
Correct Answer: A
Rationale: Separation of adjacent bones from their articulating joint interferes with normal use and produces a distorted appearance. The injury may disrupt local blood supply to structures such as the joint cartilage, causing degeneration, chronic pain, and restricted movement. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space. The fractured humerus may also be dislocated but is not the result of the impaired circulatory status. Muscle spasms may occur around the fracture site but are not the cause of circulatory impairment. Subluxation is a partial dislocation.
You may also like to solve these questions
An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse employ to minimize energy loss in response to pain?
- A. Administer prescribed analgesics around-the-clock.
- B. Administer prescribed pain medication only when the client requests it.
- C. Give pain medication to the client after providing care.
- D. Avoid administering too much medication because the client is older.
Correct Answer: A
Rationale: Pain associated with hip fracture is severe and must be carefully managed with around-the-clock dosing of pain medication to minimize energy loss in response to pain. The client may not request the medication even if they are in pain, and it should be offered at the prescribed time. Giving pain medication prior to providing any type of care involved in moving the client is appropriate to reduce discomfort.
A client has a history of dislocations of the same joint. The nurse understands that this is most likely due to an insufficient deposit of collagen during the healing process leading to what complication?
- A. Loss of function
- B. Allergic reaction
- C. Lack of mobility
- D. Reduced tensile strength
Correct Answer: D
Rationale: A possible complication of dislocation during the healing process involves an insufficient deposit of collagen during the repair stage. The end result is that the ligaments may have reduced tensile strength and future instability, leading to recurrent dislocations of the same joint. An insufficient deposit of collagen does not lead to a loss of function necessarily, allergic reaction, or a complete lack of mobility.
A client arriving at the emergency department is diagnosed with a dislocation. Assessment would most likely result in which finding(s)?
- A. Complaint of a popping sound
- B. Protrusion in the joint
- C. Swelling
- D. Pain
Correct Answer: A,C,D
Rationale: With a dislocation, a client often reports hearing a popping sound when the dislocation occurs. In addition, the structural shape is altered, with a depression noted about the joint's circumference indicating that the bones above and below are no longer aligned. Swelling, coolness, numbness, tingling, and pale or dusky color of the distal tissue also are present. Pain is a common symptom associated with dislocations.
A client sustained a sprained ankle while skiing, and the health care provider prescribed PRICE. Upon discharge, the client asks the nurse what this acronym stands for. How does the nurse respond?
- A. Protection, Rest, Ice, Compression, Elevation
- B. Prevention, Rest, Inflammation, Compression, Elevation
- C. Propping up the joint, Rate the pain, Increase activity, Compression, Elevation
- D. Perfusion, Range of motion, Ice, Circulation, Elevation, Steroids
Correct Answer: A
Rationale: Treatment consists of protecting the joint from further injury and applying ice or a chemical cold pack to the area to reduce swelling and relieve pain for the first 24 to 48 hours. Elevation of the part and compression with an elastic bandage also may be recommended. The acronym PRICE refers to protection, rest, ice, compression, and elevation - a method for remembering the treatment for strains, contusions, and sprains.
The nurse is designing a teaching plan for a client with a ruptured Achilles tendon. What education will the nurse provide?
- A. Dietary restrictions
- B. Activity restrictions
- C. Use of nonprescription medications
- D. Effective pin care
Correct Answer: B
Rationale: The nurse should emphasize information about the activity restrictions, the use of ambulatory aids, and pain management to a client with a ruptured Achilles tendon. The client need not be advised about his or her diet or the use of nonprescription medications. Teaching about pin care is also not necessary for such a client because pins are not used to treat a ruptured Achilles tendon.