Chapter 38 Assessment of Digestive and Gastrointestinal
Function
1. A nurse admits a patient who has a fracture of the nose that has resulted in a skin
tear and involvement of the mucous membranes of the nasal passages. The
orthopedic nurse is aware that this description likely indicates which type of fracture?
A) Compression
B) Compound C) Impacted D) Transverse Ans: B
Feedback:
A compound fracture involves damage to the skin or mucous membranes and is also
called an open fracture. A compression fracture involves compression of bone and is
seen in vertebral fractures. An impacted fracture occurs when a bone fragment is
driven into another bone fragment. A transverse fracture occurs straight across the
bone shaft.
2. A patient has sustained a long bone fracture and the nurse is preparing the patient's
care plan. Which of the following should the nurse include in the care plan?
A) Administer vitamin D and calcium supplements as ordered.
B) Monitor temperature and pulses of the affected extremity. C) Perform
passive range of motion exercises as tolerated.
D) Administer corticosteroids as ordered. Ans: B
Feedback:
The nurse should include monitoring for sufficient blood supply by assessing the
color,
temperature, and pulses of the affected extremity. Weight-bearing exercises are
encouraged, but passive ROM exercises have the potential to cause pain and inhibit
healing. Corticosteroids, vitamin D, and calcium are not normally administered.
,3. A nurse's assessment of a patient's knee reveals edema, tenderness, muscle spasms,
and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it ìreally
hurts to stand up.î The nurse should plan care based on the belief that the patient
has experienced what?
A) A first-degree strain
B) A second-degree strain
C) A first-degree sprain
D) A second-degree sprain
Ans: B
Feedback:
A second-degree strain involves tearing of muscle fibers and is manifested by notable
loss of load-bearing strength with accompanying edema, tenderness, muscle spasm,
and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is
accompanied by minor edema, tenderness, and mild muscle spasm, without
noticeable loss of function. However, this patient states a loss of function. A sprain
normally involves twisting, which is inconsistent with the patient's overuse injury.
,4. A nurse is preparing to discharge a patient from the emergency department after
receiving treatment for an ankle sprain. While providing discharge education, the
nurse
should encourage which of the following?
A) Apply heat for the first 24 to 48 hours after the injury. B) Maintain the ankle
in a dependent position.
C) Exercise hourly by performing rotation exercises of the ankle. D) Keep an
elastic compression bandage on the ankle.
Ans: D
Feedback:
Treatment of a sprain consists of resting and elevating the affected part, applying
cold, and using a compression bandage. After the acute inflammatory stage (usually
24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises
would likely be painful.
5. A nurse is writing a care plan for a patient admitted to the emergency department
(ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for
a patient with an open fracture of the radius?
A) Risk for Infection
B) Risk for Ineffective Role Performance
C) Risk for Perioperative Positioning Injury
D) Risk for Powerlessness
Ans: A
Feedback:
The patient has a significant risk for osteomyelitis and tetanus due to the fact that the
, fracture is open. Powerlessness and ineffective role performance are psychosocial
diagnoses that may or may not apply, and which would be superseded by immediate
physiologic threats such as infection. Surgical positioning injury is not plausible, since
surgery is not likely indicated.
Function
1. A nurse admits a patient who has a fracture of the nose that has resulted in a skin
tear and involvement of the mucous membranes of the nasal passages. The
orthopedic nurse is aware that this description likely indicates which type of fracture?
A) Compression
B) Compound C) Impacted D) Transverse Ans: B
Feedback:
A compound fracture involves damage to the skin or mucous membranes and is also
called an open fracture. A compression fracture involves compression of bone and is
seen in vertebral fractures. An impacted fracture occurs when a bone fragment is
driven into another bone fragment. A transverse fracture occurs straight across the
bone shaft.
2. A patient has sustained a long bone fracture and the nurse is preparing the patient's
care plan. Which of the following should the nurse include in the care plan?
A) Administer vitamin D and calcium supplements as ordered.
B) Monitor temperature and pulses of the affected extremity. C) Perform
passive range of motion exercises as tolerated.
D) Administer corticosteroids as ordered. Ans: B
Feedback:
The nurse should include monitoring for sufficient blood supply by assessing the
color,
temperature, and pulses of the affected extremity. Weight-bearing exercises are
encouraged, but passive ROM exercises have the potential to cause pain and inhibit
healing. Corticosteroids, vitamin D, and calcium are not normally administered.
,3. A nurse's assessment of a patient's knee reveals edema, tenderness, muscle spasms,
and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it ìreally
hurts to stand up.î The nurse should plan care based on the belief that the patient
has experienced what?
A) A first-degree strain
B) A second-degree strain
C) A first-degree sprain
D) A second-degree sprain
Ans: B
Feedback:
A second-degree strain involves tearing of muscle fibers and is manifested by notable
loss of load-bearing strength with accompanying edema, tenderness, muscle spasm,
and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is
accompanied by minor edema, tenderness, and mild muscle spasm, without
noticeable loss of function. However, this patient states a loss of function. A sprain
normally involves twisting, which is inconsistent with the patient's overuse injury.
,4. A nurse is preparing to discharge a patient from the emergency department after
receiving treatment for an ankle sprain. While providing discharge education, the
nurse
should encourage which of the following?
A) Apply heat for the first 24 to 48 hours after the injury. B) Maintain the ankle
in a dependent position.
C) Exercise hourly by performing rotation exercises of the ankle. D) Keep an
elastic compression bandage on the ankle.
Ans: D
Feedback:
Treatment of a sprain consists of resting and elevating the affected part, applying
cold, and using a compression bandage. After the acute inflammatory stage (usually
24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises
would likely be painful.
5. A nurse is writing a care plan for a patient admitted to the emergency department
(ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for
a patient with an open fracture of the radius?
A) Risk for Infection
B) Risk for Ineffective Role Performance
C) Risk for Perioperative Positioning Injury
D) Risk for Powerlessness
Ans: A
Feedback:
The patient has a significant risk for osteomyelitis and tetanus due to the fact that the
, fracture is open. Powerlessness and ineffective role performance are psychosocial
diagnoses that may or may not apply, and which would be superseded by immediate
physiologic threats such as infection. Surgical positioning injury is not plausible, since
surgery is not likely indicated.
