Nokea
A nurses assessment of a patients knee reveals edema, tenderness, muscle spasms, and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it really hurts to stand up. The nurse should plan care based on the belief that the patient has experienced what?
- A. A first-degree strain
- B. A second-degree strain
- C. A first-degree sprain
- D. A second-degree sprain
Correct Answer: B
Rationale: A second-degree strain involves tearing of muscle fibers and is manifested by notable loss of load-bearing strength with accompanying edema, tenderness, muscle spasm, and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is accompanied by minor edema, tenderness, and mild muscle spasm, without noticeable loss of function. However, this patient states a loss of function. A sprain normally involves twisting, which is inconsistent with the patients overuse injury.
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A nurse is planning the care of an older adult patient who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage which of the following? Select all that apply.
- A. Regular bone density testing
- B. A high-calcium diet
- C. Use of falls prevention precautions
- D. Use of corticosteroids as ordered
- E. Weight-bearing exercise
Correct Answer: A,B,C,E
Rationale: Health promotion measures after an older adults hip fracture include weight-bearing exercise, promotion of a healthy diet, falls prevention, and bone density testing. Corticosteroids have the potential to reduce bone density and increase the risk for fractures.
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.
Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture?
- A. Administer analgesics as required.
- B. Place a pillow between the patients legs when turning.
- C. Maintain prone positioning at all times.
- D. Encourage internal and external rotation of the affected leg.
Correct Answer: B
Rationale: Placing a pillow between the patients legs when turning prevents adduction and supports the patients legs. Administering analgesics addresses pain but does not directly protect bone remodeling and promote healing. Rotation of the affected leg can cause dislocation and must be avoided. Prone positioning does not need to be maintained at all times.
A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals?
- A. Encouraging the patient to turn from side to side and to assume a prone position
- B. Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation
- C. Minimizing movement of the flexor muscles of the hip
- D. Encouraging the patient to sit in a chair for at least 8 hours a day
Correct Answer: A
Rationale: The nurse encourages the patient to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early, because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for patients with BKAs. The nurse also discourages sitting for prolonged periods of time.
A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following?
- A. Apply heat for the first 24 to 48 hours after the injury.
- B. Maintain the ankle in a dependent position.
- C. Exercise hourly by performing rotation exercises of the ankle.
- D. Keep an elastic compression bandage on the ankle.
Correct Answer: D
Rationale: Treatment of a sprain consists of resting and elevating the affected part, applying cold, and using a compression bandage. After the acute inflammatory stage (usually 24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises would likely be painful.