musculoskeletal exam

Emergency medical technicians transport a client to the emergency department and inform the nurse that the client fell from a two-story building. The comatose client has a large contusion on the left side of the chest, a hematoma in the left parietal area, and a compound fracture of the left femur. The client was intubated and is maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag. Which intervention by the nurse has the highest priority?

Assessing the left leg

Lifestyle risk factors for osteoporosis include

lack of exposure to sunshine

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a client who has sustained a fracture. The nurse suspects which complication?

Fat embolism syndrome

With fractures of the femoral neck, the leg is

shortened, adducted, and externally rotated.

Which is one of the most common causes of death in clients diagnosed with fat emboli syndrome?

Acute respiratory distress syndrome

The health care provider is preparing to bivalve the client's cast. Which supplies should the nurse assemble?

The fractured extremity is immobilized by securing the two parts of the cast together with an **elastic compression bandage**.

The nurse is providing instructions to the client following application of a fiberglass cast. Which statement by the client indicates further education is needed?

“Under no circumstances should I get my cast wet.”

Some fiberglass casts are ____, allowing the client to shower or swim. A wet fiberglass cast is susceptible to denting while it is wet.

waterproof

\
The client is admitted to the hospital with a diagnosis of left femoral neck fracture. Which treatment modality would the nurse expect the health care provider to order?

\
\

Buck’s traction

Which intervention would the nurse implement with the client in skeletal traction? Select all that apply.

* Position trapeze within the client’s reach.
* Instruct the client on isometric exercises for immobilized extremity.
* Ensure the pins or wires are covered with caps.

The nurse is caring for the client with chronic osteomyelitis of the jaw with a draining wound. Which client goal is a priority for the client? Select all that apply.

* The client will experience a tolerable level of pain.
* The client will demonstrate wound care.
* The client will maintain adequate nutritional intake.

A client who has fractured the radial head asks the nurse about factors that will promote bone healing. Which statement should the nurse include when responding to the client? Select all that apply.

* “Immobilization of the fracture will promote healing by maximizing contact of bone fragments.”
* “Fractured bones require a good blood supply and adequate nutrition for healing.”
* “Weight bearing stimulates healing of the long bones of the leg, if the fracture is stabilized.”

A client with a fractured femur is admitted to the nursing unit. Which assessment finding requires follow up by the nurse? Select all that apply.

* "I cannot seem to catch my breath."
* "I have a pins-and-needles sensation in my toes."
* Dorsoplantar weak and unequal bilaterally
* T 101.2 degrees F; HR 110; RR 28; pulse oximetry 90%

Which of the following describes failure of the ends of a fractured bone to unite in normal alignment?

nonunion

Which of the following are associated with compartment syndrome? Select all that apply.

* Trauma from accidents
* Surgery
* Casts
* Tight bandages
* Crushing injuries

Which assessment findings would the nurse expect to find in the client with osteomyelitis?

Osteomyelitis is characterized by elevated white blood cell count and erythrocyte sedimentation rate. (normal erythrocyte less than 24 mL/hr)

What areas of the body may be examined when bone densitometry is done? Select all that apply.

hip, spine, wrist

A client who was injured while playing basketball reports an extremely painful elbow, which is very edematous. What type of injury has the client experienced?

sprain

A client has undergone a leg amputation. What teachings should the nurse offer such a client to prevent abduction deformity? Select all that apply.

* Advise the client to use a trochanter roll.
* Advise the client to adduct the stump so it presses against the other leg when the client is lying on the stomach

Which statements describe open reduction of a fracture? Select all that apply.

* It is performed in the operating room.
* The bone is surgically exposed and realigned.
* The client usually receives general or spinal anesthetic.

A client is having traction applied to a fractured left lower extremity prior to surgery. What outcomes does the nurse expect from the application of the traction for the client? Select all that apply.

* Muscle spasms will be relieved.
* The bones of the left leg will be aligned.
* Immobilization of the left leg will be maintained.

A client comes to the clinic 2 days after sustaining a sprain to the left ankle. What intervention can the nurse encourage the client to perform that will help improve circulation?

applying heat

Applying cold compresses is only used in the first ____ hours after an injury to reduce swelling and relieve pain.

24-28 hours

After 2 days, when swelling is no longer likely to increase, ____ reduces pain and relieves local edema by improving circulation

applying HEAT

A client arrives in the emergency room complaining of severe pain in her left hip after falling out of the bed. What indication upon assessment does the nurse recognize as a dislocated left hip? Select all that apply.

* The left leg is shorter than the right.
* Limited range of motion of the left hip.
* The skin of the lower left leg is pale.

A client diagnosed with osteoporosis is being discharged home. Which priority education should the nurse should provide?

* Remove all small rugs from the home

A client with osteoporosis is at risk for fractures related to ___.

falls

What assessment findings of the leg are consistent with a fracture of the femoral neck?

Shortened, adducted, and externally rotated

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply.

* Pneumonia
* Skin breakdown
* Sepsis
* Delirium

A client with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply.

* Prepare to remove the cast.
* Provide support to the injured extremity.

A client with a tibia fracture was placed in an external fixator 24 hours ago. The nurse is completing pin care and notices redness at the pin site and a small amount of serous drainage. What action by the nurse is appropriate?

* Deep vein thrombosis
* Compartment syndrome
* Fat embolism

An older adult client has fallen in the home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the client's presurgical care, the nurse should be aware of the client's heightened risk of what complication?

avascular necrosis

The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with the residual limb supported on a pillow. What is the nurse's most appropriate action?

Explain the risks of flexion contracture to the client.

A client has suffered a muscle strain and is reporting pain at 6 on a 10-point scale. The nurse should recommend what action?

Applying a COLD pack to the injured site

A client has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply

* Providing support
* Controlling movement
* Preventing additional injury

A physician writes a prescription to discontinue skeletal traction on an orthopedic client. The nurse should anticipate what subsequent intervention?

application of a cast

A client has just begun been receiving skeletal traction and the nurse is aware that muscles in the client's affected limb are spastic. How does this change in muscle tone affect the client's traction prescription?

Extra weight is needed initially to keep the limb in proper alignment.

A client is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions?

Autologous blood donation

Many clients donate their own blood during the weeks preceding their surgery, such as total hip replacement. ____ are cost effective and eliminate many of the risks of transfusion therapy

Autologous blood donation

A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge?

client is able to perform transfers safely

A nurse is caring for a client who is being assessed following reports of severe and persistent low back pain. The client is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? Select all that apply.

* Computed tomography (CT)
* Magnetic resonance imaging (MRI)
* Ultrasound
* X-ray

A client with an arm cast reports pain. What nursing interventions should the nurse provide in order to reduce the incidence of complications? Select all that apply.

* Assess the fingers for color and temperature.
* Assess for a pressure sore
* Determine the exact site of the pain.

A client has low back pain and the healthcare provider needs to rule out the presence of a tumor. Which diagnostic procedure would the nurse anticipate to be ordered for the client?

bone scan

A ___ is the preferred diagnostic procedure to disclose tumors (possible cancer) in a patient with low back pain

bone scan

A provider asks the nurse to teach a client with low back pain how to sit in order to minimize pressure on the spine. Which teaching points would the nurse include? Select all that apply.

* Sit in a straight-backed chair with arm rests.
* Avoid hip extension.
* Place feet flat on the floor.
* Sit with the buttocks “tucked under.”

A nurse is caring for a client after stabilization of a radial fracture. Which actions by the nurse would be appropriate for the client following arm casting? Select all that apply.

* Handle the cast with the palms of hands
* Circulate room air with a portable fan
* Petal and smooth the edges of the cast

normal pH level

7\.35-7.45

a pH lower than 7.35 is indicative of

acidosis

a pH higher then 7.45 is indicative of

alkalosis

a perfect pH level is

7\.4

when the body is holding on to CO2, it is ___.

acidotic

normal PaCO2 value is

35-45

normal HCO3 (bicarb) value

22-28

hydrogen ions, like potassium and chloride, in higher amounts make the body

acidic blood

decreased hydrogen ions like K+ and chloride make the blood

alkalotic

what is the **FIRST line of defense** the body uses when trying to maintain an adequate pH (homeostasis/acid-base balance)?

chemical & protein buffers

when does the body use respiratory buffers?

long term holding of oxygen (COPD pt for example)

what is the third line of defense for maintaining acid-base balance?

kidney buffers bc they can do it long term

If a patient is ___, they are in respiratory acidosis.

hypo-ventilating because of the INCREASED CARBON DIOXIDE

carbon dioxide is acidic or alkalotic?

acidic

If a patient is ___, they are in respiratory alkalosis.

hyper-ventilating because of they are BLOWING OFF TOO MUCH CO2

A nice way to remember metabolic acidosis is ___.

losing base out the butt

Losing base out the butt refers to losing fluids out of the ass such as ___.

diarrhea

When a patient is **vomiting**, the body is going into what type of acid base balance?

metabolic alkalosis bc it is coming out VERY ACID so the patient is left alkalotic

when the body **loses too much** acid (like CO2, vomit) it will be in a state of ___.

body will be in alkalosis

when the body **gains too much** acid (retention of CO2, hypoventilation) it will be in a state of ___.

body will be in acidosis

what acid base occurs with ostomy drainage?

metabolic acidosis bc the base is leaving the butt

what acid base is common in pregnant women?

respiratory alkalosis due to tachypnea (they are carrying a whole child for christ sake, of course they’re going to be tired)

why is metabolic acidosis common with **fistulas?**

bc the patient is losing base out of the butt

what lab value do HCP use to treat metabolic acid base imbalance?

anion gap

Respiratory acidosis can occur in patients while in surgery due to what meidcation?

anesthesia

why does anesthesia cause resp. acidosis?

bc anesthesia can cause resp. depression (blowing off too much CO2)

how long are you supposed to hold pressure after an **ABG?**

5-10 mins

when we inhale we take in our __, when we exhale we breathe out our __.

O2, CO2

breathing in too much O2 causes what in our body?

respiratory alkalosis bc we are taking in too much oxygen, which means the body has less CO2

less CO2 in the body (tachypnea, expelling co2) =

less acid in the blood, alkalosis

more CO2 in the body (bradypnea, inhaling co2) =

more acid in the blood, acidosis

respiratory acidosis can be caused by **DEPRESS**ION**:**

Drugs

Edema

Pneumonia

Respiratory center of the brain damage

Emboli

Spasms

Sac elasticity of alveoli

___ is the leading cause of respiratory acidosis.

respiratory depression bc the pt is blowing off too much CO2

why does pleural edema/effusion and pneumonia cause **resp. acidosis?**

the fluid build up in the lungs does not allow for CO2 to be exhaled properly, causing retention of CO2

what **assessment finding** is the biggest indicator that a patient is in resp. acidosis?

diminished lungs (the pt will not be able to properly blow off CO2=retention)

ANY disease process where a patient cannot __ their lungs, they are at risk for __.

properly expand their lungs; respiratory acidosis bc they are holding onto CO2

what **diseases** might cause **respiratory acidosis?**

asthma, pneumothorax, obesity, emphysema, COPD, chronic bronchitis, sleep apnea

____ are examples of things that compromise the respiratory center of the brain, which in turn cause the patient’s breathing to be compromised and **NOT BE ABLE TO FULLY EXPAND LUNGS** or even breathe on their own.

Stroke, aneurysm, overhydration

what kind of __surgeries__ **might limit a pt being able to fully breathe and expand lungs**, causing metabolic acidosis?

open heart surgery, broken ribs, abdominal

what assessment findings are indicative of respiratory acidosis?

bradypnea, drowsy/confused, hypotension, increased K+ levels, pale/cyanotic, HA due to no O2 to brain, EKG changes

Expelling too much CO2 puts the body in ___.

respiratory alkalosis, such as tachypnea (blowing off too much CO2)

The kidneys will try to compensate a state of respiratory alkalosis by ___.

increasing urination (excreting bicarb)

respiratory alkalosis causes TACHYPNEA:

Temperature (fever)

Aspirin toxicity

Controlled mechanical ventilation

Hyperventilation

Y hYsteria

Pain, Pregnancy

Neurological changes

Embolism

Asthma

A patient comes into the ER complaining of acute pain on his left side. The patient states “I am going to die, I just know it!” The patient is hyperventilating. His vitals signs showed the following: RR 26, HR 120, BP 138/96.

A. What might this patient be experiencing?

B. What kind of acid balance is this patient experiencing?

A. anxiety due to a “sense of doom”

B. respiratory alkalosis due to pulmonary embolism

When a patient has **acute pain** due to trauma (especially), he/she will most likely be hyperventilating or hypoventilating?

hyperventilating

___ causes **respiratory alkalosis** because the body will have increased temp & increased RR--meaning the body will be working too hard.

aspirin toxicity

respiratory alkalosis signs and symptoms include:

increased RR, increased HR, confused and tired, nausea

A patient in respiratory alkalosis will have the following labs:

low calcium levels - less than 8

low potassium levels - less than 3.5

Since a patient with respiratory alkalosis will have low CA+ & low K+, they may exhibit the following symptoms:

positive chvostek’s sign, tetany, tingling in fingers, EKG changes

how is respiratory alkalosis treated if its due to anxiety/asthma?

deep breathing

rebreathing into paper bag

administer oxygen

anxiety reduction

monitor labs

intubation may apply

Metabolic acidosis is caused by ___ with a __.

increase in CO2; decrease in bicarb HCO3

Increased acid + decrease in bicarb production causes metabolic acidosis. What are examples?

DKA, renal failure increases CO2

diarrhea decreases bicarb HCO3

Metabolic refers to what system?

GI because we are **losing base** out of the butt

What patients are at risk for metabolic acidosis?

patients with diarrhea, ileostomy/ostomy pouches, fistulas