Assessment
What is the priority assessment regarding a fracture?
a) Mechanism on injury
b) Risk of infection
c) Vital signs
d) Pain
c) Vital signs
Priority nursing diagnosis related to fracture?
Impaired physical mobility r/t loss of integrity of bone structures, movement of bone fragments, soft tissue injury, and prescribed movement restrictions
Why must the nurse emphasize the importance of elevating the extremity above the level of the heart?
a) To reduce bruising
b) To prevent skin breakdown
c) Promoting venous return and application of ice to control or prevent edema are measures frequently used during the initial phase
c) Promoting venous return and application of ice to control or prevent edema are measures frequently used during the initial phase
Which assessment is NOT part of a neuro-vascular assessment?
a) Mechanism of injury
b) Colour
c) Pulses
d) Temperature
e) Pain
a) Mechanism of injury
Fill in the blank with the BEST answer: _______ r/t open thigh wound and introduction of orthopedic pin for skeletal traction application
a) Impaired skin integrity
b) Acute pain
c) Risk for infection
c) Risk for infection
Why must a nurse emphasize the importance of not pulling out cast padding and scratching or placing foreign objects inside the cast?
It predisposes the patient to skin breakdown and infection
What is an important factor to consider when assessing a fracture site?
a) Comparing bilaterally
b) Age of the patient
c) Gender
d) Edema
a) Comparing bilaterally
Why would the nursing diagnosis of Impaired Skin Integrity be relevant to care for a fractured femur?
Immobility - increased risk of pressure ulcers
open fracture - already impaired skin integrity
A patient with a fractured femur is encouraged to perform ankle rotation exercises. You have done previous client teachings on why they need to perform ankle exercises. Which reply tells us that they understand the importance of these exercises?
a) Paresthesia is an abnormal sensation occurs when nerves are irritated or damaged
b) Ankle exercises do not prevent infection
c) Ankle exercises promote venous blood return and reduce venous stasis in the legs
c) Ankle exercises promote venous blood return and reduce venous stasis in the legs. It decreases the risk of deep vein thrombosis (DVT) in the patient's immobilized legs
What is a concerning finding you would notice when assessing a fracture?
a) Pain
b) Swelling
c) Absence of peripheral pulses
d) Discolouration
c) Absence of peripheral pulses
Name a psychosocial nursing diagnosis related to experiencing a fracture.
Ineffective self-management r/t lack of knowledge about exercise program and cast care
Why is it recommended that a patient would drink cranberry juice or absorbic acid (500-1500 mg/day)?
Drinking these fluids can help to acidify the urine and prevent calcium prescription in the urine. Renal calculi can develop as a result of bone demineralization. The hypercalcemia from demineralization causes a rise in urine pH and stone formation resulting from the precipitation of calcium
What is the MOST important to assess if there is a risk of infection?
a) Pain
b) Temperature
c) Immunization history
d) Level of consciousness
c) Immunization history
Explain the relevance of the nursing diagnosis: "risk for peripheral neurovascular dysfunction" in the care of patients with a fracture.
Vascular insufficiency and nerve compression occur from increased pressure, either from edema or mechanical compression of traction, splints, or casts
Why would medications cyclobenzaprine or methocarbamol (Robaxin) be ordered for your client with a fractured femur?
Patients with fractures often experience varying degrees of pain associated with muscle spasms. Involuntary reflexes that result from edema following muscle injury cause these spasms. These medications are central and peripheral muscle relaxants and may be prescribed for relief of pain associated with muscle spasms