Nokea
A nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a patient with an open fracture of the radius?
- A. Risk for Infection
- B. Risk for Ineffective Role Performance
- C. Risk for Perioperative Positioning Injury
- D. Risk for Powerlessness
Correct Answer: A
Rationale: The patient has a significant risk for osteomyelitis and tetanus due to the fact that the fracture is open. Powerlessness and ineffective role performance are psychosocial diagnoses that may or may not apply, and which would be superseded by immediate physiologic threats such as infection. Surgical positioning injury is not plausible, since surgery is not likely indicated.
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A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care?
- A. Preventing infection
- B. Maintaining spinal alignment
- C. Maximizing function
- D. Preventing increased intracranial pressure
Correct Answer: B
Rationale: Patients with an unstable fracture must have their spine in alignment at all times in order to prevent neurologic damage. This is a greater threat, and higher priority, than promoting function and preventing infection, even though these are both valid considerations. Increased ICP is not a high risk.
A patient has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication?
- A. Inadequate vitamin D intake
- B. Bleeding at the injury site
- C. Inadequate immobilization
- D. Venous thromboembolism (VTE)
Correct Answer: C
Rationale: Inadequate fracture immobilization can delay or prevent union. A short-term vitamin D deficiency would not likely prevent bone union. VTE is a serious complication but would not be a cause of nonunion. Similarly, bleeding would not likely delay union.
A patient who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge?
- A. Patient can demonstrate safe use of assistive devices.
- B. Patient has a healed, nontender, nonadherent scar.
- C. Patient can perform activities of daily living independently.
- D. Patient is free of pain.
Correct Answer: A
Rationale: A patient should be able to use assistive devices appropriately and safely prior to discharge. Scar formation will not be complete at the time of hospital discharge. It is anticipated that the patient will require some assistance with ADLs postdischarge. Pain should be well managed, but may or may not be wholly absent.
An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The patients description of the injury indicates that his knee was struck medially while his foot was on the ground. The nurse knows that the patient likely has experienced what injury?
- A. Lateral collateral ligament injury
- B. Medial collateral ligament injury
- C. Anterior cruciate ligament injury
- D. Posterior cruciate ligament injury
Correct Answer: A
Rationale: When the knee is struck medially, damage may occur to the lateral collateral ligament. If the knee is struck laterally, damage may occur to the medial collateral ligament. The ACL and PCL are not typically injured in this way.
A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. Which of the following is the most plausible explanation for this patients signs and symptoms?
- A. Subluxated right hip
- B. Right hip contusion
- C. Hip strain
- D. Traumatic hip dislocation
Correct Answer: D
Rationale: Signs and symptoms of a traumatic dislocation include acute pain, change in positioning of the joint, shortening of the extremity, deformity, and decreased mobility. A subluxation would cause moderate deformity, or possibly no deformity. A contusion or strain would not cause obvious deformities.