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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.
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A patient has presented to the emergency department with an injury to the wrist. The patient is diagnosed with a third-degree strain. Why would the physician order an x-ray of the wrist?
- A. Nerve damage is associated with third-degree strains.
- B. Compartment syndrome is associated with third-degree strains.
- C. Avulsion fractures are associated with third-degree strains.
- D. Greenstick fractures are associated with third-degree strains.
Correct Answer: C
Rationale: An x-ray should be obtained to rule out bone injury, because an avulsion fracture (in which a bone fragment is pulled away from the bone by a tendon) may be associated with a third-degree strain. Nerve damage, compartment syndrome, and greenstick fractures are not associated with third-degree strains.
A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patients postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care?
- A. Ineffective Thermoregulation
- B. Risk-Prone Health Behavior
- C. Disturbed Body Image
- D. Deficient Diversion Activity
Correct Answer: C
Rationale: Amputations present a serious threat to any patients body image. None of the other listed diagnoses is specifically associated with amputation.
A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication?
- A. Avascular necrosis of bone
- B. Compartment syndrome
- C. Fat embolism syndrome
- D. Complex regional pain syndrome
Correct Answer: C
Rationale: Fat embolism syndrome occurs most frequently in young adults and elderly patients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement.
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.
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.