Correct answer—C. Rationales: Severe sprains involve torn ligaments, which result in pain, swelling, and discoloration. Mild sprains cause only slight pain and swelling. Moderate sprains cause pain, swelling and limited use for a short period of time, and dislocations result in severe swelling and nerve, vein, and artery damage.

Nursing process step: Analysis

Correct answer—C. Rationales: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as pressure dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There’s no indication that diagnostic studies would require I.V. access in the affected extremity.

Nursing process step: Intervention

Correct answer—B. Rationales: A sprain results from excessive stretching or tearing of a ligament. A strain occurs from the overstretching of a tendon or muscle. A fracture is a break in the continuity of the bone as a result of excessive force. An avulsion is a full-thickness separation of the skin.

Nursing process step: Assessment

Correct answer—B. Rationales: Tendinitis is an inflammation of a tendon from excessive or continuous force. It commonly occurs in the shoulder (rotator cuff tendinitis), elbow (tennis elbow), knee (jumper’s knee), or heel (Achilles’ tendinitis). Tinnitus is ringing in the ears. Bursitis is an inflammation of the bursa, or sac, that covers a bony prominence between bones, muscles, or tendons. Nerve entrapment results from the compression of a nerve, causing ischemia of that nerve.

Nursing process step: Assessment

Correct answer—C. Rationales: Traction splints, designed for use on lower extremities, are indicated only for treating femur and proximal tibia fractures; their use in upper-extremity trauma is contraindicated. Immobilizing the shoulder, applying ice, and determining the neurovascular status distal to the injury are all appropriate interventions for a dislocated shoulder.

Nursing process step: Intervention

Correct answer—A. Rationales: Clients with a shoulder dislocation have pain with any movement of the joint. When neurovascular compromise has occurred, the client experiences numbness, paresthesia, and the inability to move the extremity.

Nursing process step: Assessment

Correct answer—B. Rationales: With a history of repetitive dislocation, the client should be evaluated by an orthopedic surgeon for possible joint fixation now, not when it becomes dislocated again. The client should be placed on restricted activity at least until follow-up is complete. The appearance of a calm, relaxed client indicates that interventions of pain control, positioning, and education have been successful.

Nursing process step: Evaluation

Correct answer—C. Rationales: The primary nursing intervention for this syndrome is administering high-flow oxygen. Airway and breathing are always top-priority interventions. After administering oxygen, the primary interventions are mechanical ventilation, if indicated, as well as fluid replacement, administration of I.V. corticosteroids, and client education.

Nursing process step: Intervention

Correct answer—D. Rationales: Applying firm in-line traction to the left leg, reassessing the distal neurovascular status, and anticipating the placement of a traction splint are the primary interventions for a client with an open femur fraction. The use of pneumatic antishock trousers is controversial, and their value for stabilizing femur fractures hasn’t been established. Protruding bone shouldn’t be pushed back into the wound. Administering oxygen to a client with a femur fracture should be done at 10 to 15 L/minute by way of a nonrebreather mask.

Nursing process step: Intervention

Correct answer—B. Rationales: A break in the skin near the site of a suspected fracture is considered an open fracture until proven otherwise. The proper care for this wound is covering it with a sterile dressing, getting wound cultures, and administering tetanus toxoid and antibiotics as ordered. The wound shouldn’t be cleaned or closed by way of a suture until an open fracture is ruled out.

Nursing process step: Intervention

Correct answer—C. Rationales: A comminuted fracture typically is transverse the shaft of the bone and has multiple splintered bone fragments. A closed fracture implies that the skin integrity at or near the point of fracture is intact. A greenstick fracture occurs when the bone buckles or bends and the fracture line doesn’t extend through the entire bone. An impacted fracture occurs when the distal and proximal portions of the fracture are wedged into each other. A compression fracture occurs when a severe force presses the bone together on itself.

Nursing process step: Analysis

Correct answer—D. Rationales: The five Ps in the neurovascular assessment of an injured extremity include pain, pallor, paresthesia, pulses, and paralysis. Purulence isn’t an assessment of neurovascular status; it’s an indication of infection.

Nursing process step: Assessment

Correct answer—B. Rationales: A tourniquet is an intervention of last resort to control bleeding. Removing the tourniquet is crucial to preserving as much of the stump as possible for the best therapeutic outcome. Caring for the amputated part, preparing for possible reimplantation, and obtaining X-rays should follow.

Nursing process step: Intervention

Correct answer—D. Rationales: Radiologic examination should be done to rule out fractures and foreign bodies. The severed part can be reimplanted many hours after amputation. It needs to be wrapped in gauze and moistened with sterile normal saline solution. Direct immersion of the amputated part results in tissue damage secondary to thermal injury. The appropriate intervention is to gently clean the amputated part to remove gross debris. Then the part should be wrapped in gauze soaked with normal saline and placed in a plastic bag. The bag should be sealed tightly, placed on ice, and monitored to ensure that the tissue doesn’t freeze.

Nursing process step: Intervention

Correct answer—D. Rationales: Amputated parts with excessive bacterial contamination and a prolonged time since the injury are less likely to be reimplanted successfully because of the increased chance of infection and the lowered viability of the limb. Both location and age may affect the outcome of the reimplantation; however, they aren’t contraindications. Adequate preservation of the amputated part would increase the success of reimplantation.

Nursing process step: Analysis

Correct answer—B. Rationales: Compartment syndrome is most likely to occur in the lower arm, hand, lower leg, and foot. These areas have limited ability to expand with increasing tissue pressures.

Nursing process step: Analysis

Correct answer—D. Rationales: Common causes of compartment syndrome include:

Preexisting joint disease doesn’t play a role in the development of compartment syndrome.

Nursing process step: Analysis

Correct answer—D. Rationales: Casting of the wrist is done after relocation to immobilize the joint and prevent redislocation. Wrist dislocations commonly result from falling onto outstretched hands and frequently are associated with sporting events. Median nerve damage can result from wrist dislocations; therefore, neurovascular assessment distal to the area of injury should be done on all clients who present with an injured extremity.

Nursing process step: Analysis

Correct answer—B. Rationales: Fasciotomy is a surgical intervention used to treat compartment syndrome. The surgeon makes longitudinal incisions along the affected extremity to relieve tissue pressure and limit compression damage. This procedure should be performed within 8 to 12 hours of the onset, before irreversible damage occurs. A muscle flap and incision and drainage aren’t interventions for compartment syndrome. Amputation is the surgical intervention of last resort.

Nursing process step: Intervention

Correct answer—A. Rationales: Nerve entrapment syndrome typically occurs in the arm. The median nerve is involved in pronator syndrome (entrapment occurs at the forearm) and carpal tunnel syndrome (entrapment at the wrist). The ulnar nerve is involved in cubital entrapment syndrome (entrapment at the elbow). The leg, thoracic vertebral column, and lumbar vertebral column aren’t involved in nerve entrapment syndromes.

Nursing process step: Analysis

Correct answer—C. Rationales: Ankle dislocations are commonly associated with fractures. Ligament strains, muscle strains, and tendon sprains don’t lead to ankle dislocations.

Nursing process step: Assessment

Correct answer—D. Rationales: Elevating the injury will decrease swelling. The client should be instructed to rest the injured extremity for the first 24 to 48 hours and then gradually increase activity as tolerated. The appropriate intervention is to apply ice for the first 24 hours to reduce swelling, then apply heat. The use of a compression elastic bandage provides support and helps to decrease swelling; it doesn’t cause compartment syndrome.

Nursing process step: Evaluation