Nokea
A client was involved in an automobile accident and sustained multiple traumas. The client has a Volkmann contracture to the right hand. What objective data does the nurse document related to this finding?
- A. Extension of the fingers of the right hand
- B. Nodules on the knuckles of the third and fourth finger
- C. Clawlike deformity of the right hand without ability to extend fingers
- D. Dislocation of the fingers
Correct Answer: C
Rationale: A Volkmann contracture is a clawlike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. The client is unable to extend the fingers and reports unrelenting pain, particularly if attempting to stretch the hand. Nodules on the knuckles and dislocation are not indicative of Volkmann contracture.
You may also like to solve these questions
A client arrives at the orthopedic clinic and reports suspecting a stress fracture of the right foot. The physician orders an x-ray with negative results. What does the nurse understand that these negative results can mean?
- A. The client does not have a stress fracture
- B. The client probably has a strain
- C. The stress fracture may not be seen on x-ray for a few weeks.
- D. The physician may have misread the x-ray.
Correct Answer: C
Rationale: A stress fracture may not be apparent radiographically for a few weeks. A bone scan usually can identify a nondisplaced or stress fracture earlier than an x-ray.
A client was playing softball and was hit in the right ankle by the ball, sustaining a contusion. What is the first action the nurse takes to help alleviate pain and swelling?
- A. Apply heat to the ankle.
- B. Apply a cold pack to the ankle.
- C. Administer ibuprofen (Advil).
- D. Ask the client to walk to stretch the ligaments.
Correct Answer: B
Rationale: Applying cold packs helps to alleviate local pain, swelling, and bruising. Heat is not used initially after injury, because it can dilate the blood vessels, causing increased bruising and pain. Ibuprofen (Advil) would not be a priority action at this time. The client should not walk on the injured foot or ankle until serious injury is ruled out.
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 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.
A client comes to the clinic 2 days after sustaining a sprain to the left ankle. What intervention can the nurse encourage the client to perform that will help improve circulation?
- A. Active range-of-motion exercises
- B. Take nonsteroidal anti-inflammatory drugs
- C. Applying cold compresses
- D. Applying heat
Correct Answer: D
Rationale: After 2 days, when swelling is no longer likely to increase, applying heat reduces pain and relieves local edema by improving circulation. Full use of the injured joint is discouraged temporarily. Nonsteroidal anti-inflammatory drugs will ease discomfort but not improve circulation. Applying cold compresses is only used in the first 24 to 48 hours after an injury to reduce swelling and relieve pain.