2024 PEARSON NCLEX
MUSCULOSKELETAL TRAUMA
EXAM WITH CORRECT
ANSWERS
A healthy, active 73 year old client who suffered a fracture of the fibula has
suffered a severely sprained right ankle and is preparing to leave the
Emergency Department. Which of the following aids to ambulation would be
most appropriate for the client?
A. Wheel chair
B. Crutches
C. Walker
D. Cane - CORRECT ANSWERS-A. Wheel chair
Older clients will usually find a walker best suited to their needs. With aging,
muscle mass in the upper extremities declines, making crutch walking
problematic. The client may eventually be able to use a cane, but not during
the initial post-injury phase. A wheel chair would be considered if the client
were frail or had impaired ambulation skill.
The client suffered a fractured pelvis after being struck by an automobile two
hours ago. Since admission, the client's blood pressure has steadily
decreased while the pulse rate has steadily increased. The client's most
recent hemoglobin level has declined 1 gm/dL since admission. The
physician should be notified because the client is demonstrating signs of
A. Post traumatic stress syndrome.
B. Hypovolemia.
C. Head injury.
D. Homeostasis. - CORRECT ANSWERS-B. Hypovolemia.
Increased heart rate, decreased blood pressure, and decreasing hemoglobin
levels may indicate bleeding into the pelvis leading to hypovolemia. The
onset of Post Traumatic Stress Syndrome generally is recognized after
physical healing takes place and is characterized by psychosocial symptoms.
There are no indications of head injury (such as decreasing level of
consciousness). Homeostasis would be indicated by stabilization of vital
signs and hemoglobin levels.
, Which of the following statements, if made by the client, indicate to the
nurse that teaching regarding home therapy for a severe left ankle sprain
has been successful?
A. "I'll gently rotate the left ankle, use intermittent compression on it, and
exercise it slowly."
B. "I'll plan to keep my left ankle resting on two pillows, use an ace bandage
around it, and ice my ankle."
C. "I'll use RICES: regulate my pain medication, keep ice on the ankle at all
times, contract and relax my toes, and evenly space walking requirements."
D. "I'll make regular observations of my ankle bruising, indicate on a notepad
when I apply weight to my ankle, clean the skin daily, and empty the icepack
when the ice melts." - CORRECT ANSWERS-B. "I'll plan to keep my left ankle
resting on two pillows, use an ace bandage around it, and ice my ankle."
RICE serves as an acronym to indicate to the client the treatment plan of
resting the ankle (no rotation, exercise, walking or weight bearing during the
initial treatment phase); applying ice (to cause vasoconstriction and reduce
pain); use a compression appliance, such as an ace bandage (to decrease
edema formation and pain); and, elevate the injured extremity on pillows (to
decrease edema and pain).
The aged client fell from a bench to the floor and dislocated the right
shoulder. The client is admitted to the hospital overnight. The flow sheet
indicated that 10 p.m. neurovascular check of the right upper extremity was
within normal limits. The nurse makes rounds at midnight, and makes the
gathers the following data: right upper extremity pale; unable to move the
lower arm; absent radial and antecubital pulses; and, client's description of
"terrible pain" in the right shoulder and arm. The nurse's first response is to:
A. contact the physician.
B. recheck the findings in one hour.
C. reposition the extremity and reapply ice to the shoulder.
D. administer pain medication. - CORRECT ANSWERS-A. contact the
physician.
The data the nurse has gathered indicates that the client's neurovascular
status has deteriorated and that tissue death may occur if intervention is not
taken. The nurse should contact the physician, report the findings, and
document the problem, action taken, and client response to intervention as
prescribed by the physician.
The 64 year old male client dislocated the left shoulder while playing tennis.
The client tells the Emergency Department nurse that the client has
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