Nokea
The nurse is caring for a client with a fracture. Which assessment would take priority?
- A. Neurovascular compromise
- B. Hormonal imbalances
- C. Cardiac problems
- D. Altered kidney function
Correct Answer: A
Rationale: When caring for a client with a fracture, the nurse assesses for the neurovascular compromise. A fracture or a treatment for fracture is not known to lead to hormonal imbalances, cardiac problems, or an altered kidney function.
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A client comes to the emergency department complaining of localized pain and swelling of the lower leg. Ecchymotic areas are noted. History reveals that the client was hit in the leg with a baseball bat. What would the nurse suspect as most likely?
- A. Fracture
- B. Contusion
- C. Sprain
- D. Strain
Correct Answer: B
Rationale: The client's description of blunt trauma by a baseball bat and localized pain in conjunction with swelling and ecchymosis would most likely suggest a contusion. A fracture would be manifested by pain, loss of function, deformity, swelling, and spasm. A sprain would be manifested by pain and swelling; ecchymosis may appear later. A strain is characterized by inflammation, local tenderness, and muscle spasms.
The nurse is caring for a client who reports wrist pain. What does the nurse identify as a positive indicator of the Phalen sign?
- A. Percussion of the median nerve causes tingling and numbness.
- B. Wrist flexion for 30 seconds causes pain and numbness.
- C. Electrical stimulation shows a delay in motor responses.
- D. Shaking hands causes a reduction in the pain
Correct Answer: B
Rationale: Phalen sign involves having the client flex the wrist for 30 seconds to determine if pain or numbness occurs, which if it does, indicates a positive sign for carpal tunnel syndrome. Tinel sign involves percussion of the median nerve, which if positive, elicits tingling, numbness, and pain for clients with carpal tunnel syndrome. Electrical stimulation with delay would be evaluated by electromyography. Shaking hands that leads to a reduction in pain is a method for assessing carpal tunnel syndrome.
A client comes to the emergency department and it is found that the client's radial head is partially dislocated. What is this partially dislocated radial head documented as?
- A. Volkmann's contracture
- B. Subluxation
- C. Compartment syndrome
- D. Sprain
Correct Answer: B
Rationale: A partial dislocation is referred to as a subluxation. A Volkmann contracture is a claw-like deformity that results from compartment syndrome or obstructed arterial blood flow to the forearm and hand. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space and affects nerve innervation, leading to subsequent palsy. A sprain is injury to the ligaments surrounding the joint.
A client with metastatic bone cancer sustained a left hip fracture without injury. What type of fracture does the nurse understand occurs without trauma or fall?
- A. Impacted fracture
- B. Transverse fracture
- C. Compound fracture
- D. Pathologic fracture
Correct Answer: D
Rationale: A pathologic fracture is a fracture that occurs through an area of diseased bone and can occur without trauma or a fall. An impacted fracture is a fracture in which a bone fragment is driven into another bone fragment. A transverse fracture is a fracture straight across the bone. A compound fracture is a fracture in which damage also involves the skin or mucous membranes.
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.