HESI Patient Review 2 Danny PDF

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HESI Patient Review, Adult Health, Musculoskeletal Health, Danny Elington: 

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You are a nurse working on an Adolescent Unit of a large suburban hospital. Danny Ellington, age 17, has just been admitted to your unit from the Emergency Department (ED). He fractured his right femur and right wrist when tackling a teammate on the football field during football practice at school. Danny's wrist fracture is a closed Colles' fracture. A Colles' fracture involves a break in the radius at the epiphysis within one inch of the wrist joint. Colles' fractures occur in all age groups, although certain fracture patterns vary by age group. In a young person like Danny, a relatively high energy force is needed to cause the fracture, and the fracture tends to be complex and intraarticular. Danny's femur fracture is an open fracture, which caused a large skin wound. The skin wound was full of dirt and blood when Danny was admitted. Blood loss from a fractured femur can be significant. You receive report on Danny from the Emergency Department (ED) nurse, and note medication orders that have just been written.

 You review assessment data already entered in Danny's record, and proceed to assess Danny and collect other data. Given Danny's fractures, which of the following do you expect?  Pain in the right upper leg  An open fracture of the femur (in the upper leg) causes soft tissue trauma, and immediately causes pain, secondary to inflammation and swelling.  Footdrop in the right foot  Footdrop (plantar flexion) can occur as a LATE complication of leg fracture, secondary to ankle immobility. However, footdrop is not expected at this time. Suspension traction to treat a leg fracture should include a foot support designed to prevent footdrop.  Swelling in right thigh  Swelling at the fracture site is a classic sign of a fracture, especially an open fracture that is accompanied by soft tissue damage with inflammation.

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Ecchymosis is also common at a fracture site, secondary to local tissue damage and bleeding blood vessels.  Pain in right wrist  A Colles' fracture is expected to be painful, secondary to tissue trauma, inflammation, and swelling.  Danny's femur fracture is an open fracture, and his wound was dirty. With an open fracture and a dirty wound there is increased risk for developing which of the following infections?  Trichinosis  Danny is not at risk for trichinosis. Trichinosis is an infestation by roundworms. It usually develops after ingesting pork contaminated with Trichinella spiralis.  Tetanus  Danny is at risk for developing tetanus. The tetanus bacillus can potentially be introduced into the body through a wound contaminated with dirt, soil, or dust. The tetanus bacillus produces a toxin (Clostridium tetani) which can grow anaerobically at the site of injury and cause tetanus with its associated local and systemic manifestations.  Hepatitis  Danny is not at risk for developing hepatitis. Hepatitis involves viral or toxic inflammation of the liver and is unrelated to fractures or contaminated wounds.  Botulism  Danny is not at risk for developing botulism. Botulism is a severe form of food poisoning caused by ingesting food contaminated with Clostridium botulinum. Because of Danny's risk for tetanus, his immunization history was carefully checked in the Emergency Department (ED). His most recent tetanus booster was administered when he was 14, three years ago. No further immunization against tetanus is needed at this time. Tetanus boosters are recommended every ten years. With serious injuries like Danny's, however, a booster would be given if the most recent one was administered more than five years prior to the time of injury. You have reviewed Danny's medical record and now proceed to his room and introduce yourself. Danny is uncomfortable but pleasant. He says he can't believe he won't be able to play football again this season!  All of the following assessments are indicated. Which nursing assessment takes priority at this time?  Vital signs  Close monitoring of vital signs is necessary for early detection of lifethreatening complications of serious fractures such as shock, fat emboli, and pulmonary emboli. Tachycardia would occur with all three complications. In addition, urine output should be monitored for a decrease. Oliguria would characterize shock.  Pain level

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Assessing pain level is important but not the most important assessment at this time.  Skin condition  Evaluating skin condition is important but other assessments take priority at this early stage after injury.  Traction alignment  Assessing traction alignment is important but not the most important assessment at this time. Danny's vital signs are stable. A large dressing covers a wound on his right thigh. It is dry and intact with a quarter-size area of dried blood noted. Danny received medication for pain one hour ago and is relatively comfortable.  Danny asks about his skeletal traction. Which of the following explanations of skeletal traction would be accurate?  Skeletal traction is applied directly to bone  Skeletal traction is applied directly to bone by means of pins or wires inserted distal to the fracture site.  Skeletal traction should help prevent damage to the tissues near the fracture site  Skeletal traction immobilizes broken bones and reduces muscle spasm and contraction. This helps prevent damage to surrounding tissues.  Skeletal traction is designed to prevent movement at the fracture site  Skeletal traction immobilizes the fracture area. This prevents further damage to bone and surrounding tissues and reduces pain. In addition, immobilization insures maintenance of proper alignment of bone while healing progresses.  Skeletal traction should help restore bone fragments at the fracture site to their normal position  Contraction of muscles adjacent to fractured bones can prevent optimal restoration (reduction) of fractured bone and bone fragments to their normal position. Skeletal traction immobilizes the fracture site and reduces muscle spasm and contraction that could interfere with optimal reduction.  Skeletal traction involves insertion of a pin that will permanently remain in the bone  The pins inserted for application of skeletal traction are removed when traction is no longer necessary. Danny will have surgery on his leg. Skeletal traction is being used temporarily to reduce Danny's unstable femur fracture in preparation for surgery. In the meantime, conscientious care of Danny, his cast, and his traction is indicated. A physical therapist will visit Danny and develop an exercise plan designed to maintain muscle function and prevent contractures, and other complications of immobility.  When evaluating Danny's skeletal traction apparatus, it is important to ensure that:  Danny's body is maintained in proper alignment  Optimal traction force is exerted when proper body alignment is maintained.  rope knots fit snugly into pulleys

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With skeletal traction, knots should be free of pulleys. Knots caught in the pulleys interrupt the necessary traction force. Traction force should be continuously applied.  the footplate that supports Danny's foot touches the foot of the bed  With skeletal traction, the footplate should not touch the foot of the bed. If the footplate touches the foot of the bed, the traction force will be interrupted.  the weights that apply traction force are intermittently removed  With skeletal traction, weights should hang free and not be removed. If the weights are removed, the traction force is interrupted. Traction force should be continuously applied. You explain to Danny the need to keep his body aligned properly. You also explain the need to keep the weights applied at all times. You then proceed to carefully examine Danny's pin sites. With skeletal traction, pins or wires are inserted through bone so that traction weights can be applied.  You observe that Danny's pin site dressing is dry, but some watery serous drainage is oozing from the pin site, which is slightly reddened. In response to these data, which of the following is indicated?  Document your findings  Watery serous oozing and slight redness are considered normal at this time. These occur secondary to the normal inflammatory process. Documenting your findings is appropriate. There is no need to notify the physician of your findings, since these findings are expected at this time.  Document your findings and verbally notify the physician the next time you see him  Watery serous oozing and slight redness are considered normal at this time. There is no need to notify the physician.  Notify the physician stat and document your findings  Watery serous oozing and slight redness are considered normal at this time. There is no need to notify the physician. Bright red blood observed at pin sites would indicate active bleeding and would not be expected at this time (so many hours after pin insertion). This observation would need to be reported immediately. Thick yellow drainage (purulent drainage) or a foul odor noted at pin sites would indicate infection. These observations would need to be reported immediately. Based on your initial assessment of Danny and data obtained from the Emergency Department (ED) report, you develop a plan of care for Danny.  Which of the following patient problems are applicable to Danny?  Ineffective Airway Clearance  Danny has not sustained any injury to his airways and no airway problem is anticipated. Ineffective Airway Clearance is not applicable at this time.  Risk for Infection  Danny is at Risk for Infection because of his open thigh wound and the introduction of an orthopedic pin used to apply skeletal traction. Danny has

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been placed on Ancef (cefazolin) prophylactically. Nurses will provide meticulous wound care and administer prescribed antibiotics.  Acute Pain  Danny will experience pain from his fractures, tissue damage, and skeletal traction. Nursing comfort measures in association with prescribed analgesics should help to reduce Danny's pain.  Impaired Skin Integrity  Danny will be confined to bed and necessarily be immobilized for some time. He will therefore be at risk for the development of pressure ulcers. He already has impaired skin integrity because of his leg wound. This statement represents an appropriate problem that applies for Danny's care. Nursing measures including frequent turning and positioning and meticulous skin care should help prevent pressure ulcers.  Self-Care Deficit  Because of his right arm cast and leg traction, Danny will need assistance with hygiene, toileting, eating, etc. This statement represents an appropriate problem that applies for Danny. Nursing interventions will insure that these basic needs are met as independently as possible.  Risk for Injury  Because Danny will be confined to bed and forced to cope with traction and a cast that he is unfamiliar with, he is at Risk for Injury. He may try to move inappropriately or reach for something without safety precautions being implemented. Risk for Injury is a problem that can be addressed through nursing interventions designed to prevent injury, such as teaching Danny about his devices, proper moving techniques, and related safety measures.  Risk for Constipation  Immobility often causes decreased peristalsis and poor appetite. These can contribute to constipation. A high-fiber diet and perhaps stool softeners, in conjunction with a high fluid intake and as much movement in bed as possible, should help prevent constipation. While hanging Danny's IV Ancef (cefazolin), he asks you what the medicine is for. You tell him that Ancef (cefazolin) is an antibiotic, being given to prevent infection.  Danny asks you why he can't take his medicine by mouth. Which of the following explanations would be accurate?  "This medication might upset your stomach."  Ancef (cefazolin) is a cephalosporin. Although stomach irritation is possible when cephalosporins are administered orally, this rarely occurs. Also, the possibility of GI upset is not the reason for IV administration of Ancef (cefazolin) to Danny.  "This medication doesn't come in an oral form."  Ancef (cefazolin) is a cephalosporin available in many oral preparations.  "We don't want you to have anything by mouth."  There is no reason to restrict Danny's oral intake at this time.  "The medication would not be as effective if taken by mouth."

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Bone tissue has limited vascular supply, and a high blood concentration of Ancef (cefazolin) is desired. A higher blood concentration can be achieved with intravenous administration. Danny is receiving an antibiotic to prevent osteomyelitis, which is a serious complication of fracture. Osteomyelitis involves infection of bone tissue.  Monitoring Danny for signs/symptoms of osteomyelitis is important. Signs/symptoms of osteomyelitis commonly include:  fever  Fever is a common response of the body to a serious bacterial infection. Onset of fever may be abrupt, with accompanying chills and malaise.  jaundice  Jaundice occurs when serum bilirubin is elevated. This generally occurs with disorders of the gallbladder or liver, not the bone.  generalized rash  A generalized rash is not a sign of bone infection.  localized bone tenderness  With bone infection, inflammation initiates an increase of blood cells and fluid to the site. Tenderness and pain occur secondary to swelling and irritation of nerve endings.  localized swelling  With bone infection, inflammation initiates an increase of blood cells and fluid to the site. Swelling would be observed.  localized erythema  With bone infection, inflammation initiates an increase of blood cells and fluid to the site. Redness and warmth to touch would be observed. You will observe Danny for signs and symptoms of osteomyelitis. Currently Danny is afebrile and has no signs or symptoms of osteomyelitis.  You proceed with a general assessment of Danny. Which of the following assessments are relevant and appropriate at this time?  Danny's lips  There is no reason to focus your assessment on Danny's lips. The lips normally reflect pallor (from poor circulation or anemia) or cyanosis (poor circulation or problem with oxygenation), neither of which is anticipated at this time.  The fingers on Danny's right hand  Because Danny has a cast on his right arm from his fingers to above his elbow, a neurovascular assessment should be done to insure that circulation and nerve function in his arm and hand are normal. Comparison should be made with his unaffected hand. Danny's fingers should be checked for capillary refill time, color, and temperature. Capillary refill time should be less than 3 seconds, color should be pink, and temperature should be warm. In addition, motor function should be checked by asking Danny to move his fingers. Inability to move his fingers or complaints of numbness or tingling would suggest impaired nerve function.

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Danny's coccyx  Because Danny will be confined to bed and mostly on his back, his coccyx should frequently be checked for signs of excessive pressure or skin breakdown. In African-Americans, excessive pressure causes skin to have blue or purple tones. Danny's coccyx shows no signs of excessive pressure at this time.  The toes on Danny's right foot  Because Danny has had pins inserted and traction is applying pressure to his leg, a neurovascular assessment should be done to insure that circulation and nerve function in his leg are normal. Comparison should be made with his unaffected leg. Danny's toes should be checked for capillary refill time, color, and temperature. Capillary refill time should be less than 3 seconds, color should be pink, and temperature should be warm. In addition, motor function should be checked by asking Danny to move his toes. Inability to move his toes or complaints of numbness or tingling would suggest impaired nerve function.  Danny's heels  Because Danny will be confined to bed and mostly on his back, his heels should frequently be checked for signs of excessive pressure or skin breakdown. In African-Americans, excessive pressure causes skin to have blue or purple tones. Danny's heels shows no signs of excessive pressure at this time. Danny's toes on his affected leg are pink and warm. He is able to move them freely. Danny's fingers on his affected arm (which is lying flat on his bed) are pale but warm, with a good capillary refill time. Danny is able to move his fingers, but some minimal swelling makes this somewhat difficult.  Which of the following nursing actions is indicated in response to your observation of swelling in Danny's fingers?  Notify the physician immediately  Trauma at Danny's wrist has initiated the normal inflammatory response. Some swelling is expected. Notifying the physician is not indicated.  Elevate Danny's hand on a pillow  Trauma at Danny's wrist has initiated the normal inflammatory response. Some swelling is expected. This swelling can be alleviated by elevating Danny's hand higher than his elbow, such as on a pillow. This should decrease swelling by gravity flow.  Move Danny's hand so it dangles over the side of the bed  Trauma at Danny's wrist has initiated the normal inflammatory response. Some swelling is expected. This swelling can be alleviated with another intervention. Swelling would likely increase if Danny's hand was allowed to dangle over the side of the bed. Fifteen minutes later, you return to check Danny's fingers on his casted hand. Even though you have elevated Danny's right wrist on a pillow, swelling has increased.

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Danny's fingers are now cool, pale, and feel hard to the touch. Capillary refill time is sluggish. Danny complains that his arm is more painful and feels tight and "tingly."  Which of the following nursing actions should you implement at this time?  Elevate Danny's right wrist on two pillows  Pallor, coolness, and sluggish capillary refill suggest inadequate arterial circulation to Danny's arm and hand. Elevating his wrist above heart level would further decrease arterial blood supply to his arm and hand and should be avoided.  Continue to monitor Danny's fingers at frequent intervals  Continued observation without intervention could be dangerous for Danny! Pallor, coolness, and sluggish capillary refill suggest inadequate arterial circulation to Danny's arm and hand.  Notify the physician immediately  Pallor, coolness, tingling, and sluggish capillary refill suggest inadequate arterial circulation to Danny's arm and hand. These are classic signs of compartment syndrome (inadequate arterial blood supply to tissues secondary to severe inflammatory edema in a confined space). Immediate medical intervention is indicated! Compartment syndrome occurs when excess pressure constricts the structures within a compartment, and reduces circulation to muscles and nerves. Compartment syndrome can result from hemorrhage and edema within a compartment following a fracture, or it can be a result of external compression of a limb by a cast. Early recognition and treatment of compartment syndrome are essential in avoiding permanent damage to muscles and nerves.  Encourage finger exercises  Pallor, coolness, and sluggish capillary refill suggest inadequate arterial circulation to Danny's arm and hand. This is an emergency situation in which finger exercises are not indicated! The physician responds to your call immediately, and opens Danny's cast edges to relieve the accumulating pressure. Danny's fingers immediately become pink and warm!  Quadriceps setting exercises have been ordered for Danny to improve the stability of his knees. Which of the following responses would indicate that Danny understands instructions given on quadriceps setting exercises?  "I will tighten my foot muscles.”  Quadriceps setting exercises do not involve tightening of the foot muscles.  "I will tighten my abdominal muscles.”  Quadriceps setting exercises do not involv...