Nokea
An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply.
- A. Loss of visual acuity
- B. Adverse medication effects
- C. Slowed reflexes
- D. Hearing loss
- E. Muscle weakness
Correct Answer: A,B,C,E
Rationale: Older adults are generally vulnerable to falls and have a high incidence of hip fracture. Weak quadriceps muscles, medication effects, vision loss, and slowed reflexes are among the factors that contribute to the incidence of falls. Decreased hearing is not noted to contribute to the incidence of falls.
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A patient has sustained a long bone fracture and the nurse is preparing the patients care plan. Which of the following should the nurse include in the care plan?
- A. Administer vitamin D and calcium supplements as ordered.
- B. Monitor temperature and pulses of the affected extremity.
- C. Perform passive range of motion exercises as tolerated.
- D. Administer corticosteroids as ordered.
Correct Answer: B
Rationale: The nurse should include monitoring for sufficient blood supply by assessing the color, temperature, and pulses of the affected extremity. Weight-bearing exercises are encouraged, but passive ROM exercises have the potential to cause pain and inhibit healing. Corticosteroids, vitamin D, and calcium are not normally administered.
A patient with a simple arm is receiving discharge education from the nurse. What would the nurse instruct the patient to do?
- A. Elevate the affected extremity to shoulder level when at rest.
- B. Engage in exercises that strengthen the unaffected muscles.
- C. Apply topical anesthetics to accessible skin surfaces as needed.
- D. Avoid using analgesics so that further damage is not masked.
Correct Answer: B
Rationale: The nurse will encourage the patient to engage in exercises that strengthen the unaffected muscles. Comfort measures may include appropriate use of analgesics and elevation of the affected extremity to the heart level. Topical anesthetics are not typically used.
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.
A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse recognizes that the patient has likely sustained what?
- A. Sprain
- B. Strain
- C. Contusion
- D. Dislocation
Correct Answer: C
Rationale: A contusion is a soft-tissue injury that results in bleeding into soft tissues, creating a hematoma and ecchymosis. A sprain is an injury to ligaments caused by wrenching or twisting. A strain is a muscle pull from overuse, overstretching, or excessive stress. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact. Because the injury is not at the site of a joint, the patient has not experienced a sprain, strain, or dislocation.
The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patients room and finds him resting in bed with his residual limb supported on pillow. What is the nurses most appropriate action?
- A. Inform the surgeon of this finding.
- B. Explain the risks of flexion contracture to the patient.
- C. Transfer the patient to a sitting position.
- D. Encourage the patient to perform active ROM exercises with the residual limb.
Correct Answer: B
Rationale: The residual limb should not be placed on a pillow, because a flexion contracture of the hip may result. There is no acute need to contact the patients surgeon. Encouraging exercise or transferring the patient does not address the risk of flexion contracture.