ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 51 : Care of Patients with Musculoskeletal Trauma Questions
Question 1 of 5
A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)
Correct Answer: A,C,D
Rationale: Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, unequal pulses are caused by increased production of lactic acid, and cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, not increased blood flow, and tingling is caused by increased tissue pressure, not histamine release.
Question 2 of 5
A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this client's teaching? (Select all that apply.)
Correct Answer: A,B,C,E
Rationale:
To prevent carpal tunnel syndrome, the nurse should teach the client to assess the ergonomics of their workspace, take breaks to stretch fingers and wrists, perform wrist exercises to strengthen muscles, and use wrist splints during repetitive tasks. Adjusting activities to increase pain and swelling would worsen the condition and should not be recommended.
Question 3 of 5
These symptoms represent early warning signs of acute compartment syndrome. Which action should the nurse take first?
Correct Answer: A
Rationale: These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesia precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a provider's prescription.
Question 4 of 5
Which action should the nurse take to ensure proper traction management?
Correct Answer: D
Rationale: Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the client's skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP.
Question 5 of 5
A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?
Correct Answer: A
Rationale: A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the client's arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.