Chapter 32: Care of Patients with Musculoskeletal and Connective Tissue Disorders |deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

MULTIPLE CHOICE 1. A patient has come to the ambulatory care clinic with a sprain. The nurse correctly differentiates a grade 2 sprain from a grade 3 sprain with the assessment of which finding? a. Pain b. Swelling c. Bleeding into the joint d. Minor loss of function ANS: D The minor loss of function is the differentiating factor. Pain, swelling, and bleeding into the joint are true of both grade 2 and grade 3 sprains. A grade 3 sprain has loss of function of the joint. PTS:1 DIF: Cognitive Level: Application REF: 735 OBJ:1(theory) TOP: Sprains: Grade 2 KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. An older adult has fallen and sprained his ankle in a local park. Which action should the responder perform first? a. Elevate the foot. b. Apply ice. c. Administer aspirin. d. Assist the patient with ambulation. ANS: A Elevation to reduce swelling is the most important initial intervention. Elevation may be done immediately. The responder will have to acquire the ice and pain medication, but should do so as quickly as possible. The responder should not attempt to ambulate the patient at this time. PTS:1 DIF: Cognitive Level: Analysis REF: 735 OBJ:1 (theory) TOP: Sprain: First Aid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. When the clinic nurse starts to take the “air cast” off the grade 2 sprain, the patient asks why it is being removed since he still has pain. Which explanation is best? a. “Long-term immobilization can interfere with adequate circulation.” b. “Long-term immobilization may increase long-term edema.” c. “Long-term immobilization can cause permanent disability.” d. “This cast will be replaced with a heavier cast.” ANS: C Air casts, braces, or supports are used only until a joint has been strengthened. If a joint is immobilized too long and muscles are not exercised, muscle atrophy—which begins in a matter of days—can cause permanent disability PTS:1 DIF: Cognitive Level: Application REF: 735 OBJ:1 (theory) TOP: Splinted Sprain: Complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. Which statement indicates that the patient needs further instruction about application of ice to a sprain? a. “I know this ice will reduce the swelling.” b. “I will keep the ice on this knee for the rest of the day.” c. “I will use the ice as you have directed for 24 hours.” d. “I can elevate my leg and use ice to reduce swelling.” ANS: B Ice should be applied for 20 minutes of each hour for the first 24 hours. PTS:1 DIF: Cognitive Level: Application REF: 735 OBJ:1 (theory) TOP: Ice: Duration of Application KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 5. The industrial nurse examines an employee who complains of right shoulder pain on abduction. He points with one finger to the exact location of the pain and mentions that he won a racquetball tournament yesterday. The nurse suspects the employee is suffering from which problem? a. Rotator cuff tear b. Bursitis c. Dislocation d. Subluxation