Chapter 41 Management of Patients with musculoskeletal disorders

Assessment of a client reveals signs and symptoms of Paget's disease. Which of the following would be most likely? A.) Skull narrowing B.) Lordosis C.) Long bone bowing D.) Upright gait

Answer: C.) Long bone bowing Rationale: Some clients with Paget's disease are asymptomatic with only some mild skeletal deformity. Other clients have marked skeletal deformities which may include enlargement of the skull, bowing of the long bones, and kyphosis.

A client has Paget's disease. An appropriate nursing diagnosis for this client is: A.) Risk for infection B.) Delayed wound healing C.) Risk for falls D.) Fatigue

Answer: C.) Risk for falls Rationale: The client with Paget's disease is at risk for falls secondary to pathological fractures and impaired gait/mobility.

Which term refers to a disease of a nerve root? A.) Radiculopathy B.) Involucrum C.) Sequestrum D.) Contracture

Answer: A.) Radiculopathy Rationale: When the client reports radiating pain down the leg, the client is describing radiculopathy. Involucrum refers to new bone growth around the sequestrum. Sequestrum refers to dead bone in an abscess cavity. Contracture refers to abnormal shortening of muscle or fibrosis of joint structures.

Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing bone mass density (BMD)? A.) Calcitonin B.) Raloxifene C.) Teriparatide D.) Vitamin D

Answer: A.) Calcitonin

A nurse is caring for a client with bone metastasis from a primary breast cancer. The client reports muscle weakness and nausea and is voiding large amounts frequently. The telemetry monitor is observed showing premature ventricular contractions. What should the nurse suspect based on the clinical manifestations? A.) Hypercalcemia B.) Hypocalcemia C.) Hypokalemia D.) Hyperkalemia

Answer: A.) Hypercalcemia Rationale: Hypercalcemia is present with bone metastases from breast, lung, or kidney cancer. Symptoms of hypercalcemia include muscle weakness, fatigue, anorexia, nausea, vomiting, polyuria, cardiac dysrhythmias such a premature ventricular contractions, seizures, and coma. Hypercalcemia must be identified and treated promptly. Hypocalcemia will not be seen with bone cancer. Hypokalemia and hyperkalemia are not common with bone metastasis.

Which is not a risk factor for osteoporosis? A.) being male B.) small-framed, thin White or Asian women C.) being postmenopausal D.) family history

Answer: A.) being male

Which group is at the greatest risk for osteoporosis? A.) Men B.) Caucasian women C.) Asian women D.) African American women

Answer: B.) Caucasian women

A patient is having low back pain. What position can the nurse suggest to relieve this discomfort? A.) High-Fowler's to allow for maximum hip flexion B.) Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees C.) Prone, with a pillow under the shoulders D.) Supine, with the bed flat and a firm mattress in place

Answer: B.) Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees Rationale: A medium to firm, not sagging mattress (a bed board may be used) is recommended; there is no evidence to support the use of a firm mattress (National Guideline Clearinghouse, 2010). Lumbar flexion is increased by elevating the head and thorax 30 degrees by using pillows or a foam wedge and slightly flexing the knees supported on a pillow. Alternatively, the patient can assume a lateral position with knees and hips flexed (curled position) with a pillow between the knees and legs and a pillow supporting the head (Fig. 42-1). A prone position should be avoided because it accentuates lordosis.

A healthcare provider asks a nurse to test a client for Tinel's sign to diagnose carpal tunnel syndrome. What should the nurse do to perform this assessment? A.) Have the client make a fist and open the hand against resistance. B.) Have the client stretch the fingers around a ball and squeeze with force. C.) Have the client hold the palm of the hand up while the nurse percusses over the median nerve. D.) Have the client pronate the hand while the nurse palpates the radial nerve.

Answer: C.) Have the client hold the palm of the hand up while the nurse percusses over the median nerve. Rationale: If tingling, numbness, or pain is felt when the median nerve is percussed, then Tinel's sign is considered positive. To test for Tinel's sign have the client hold the palm of the hand up while the nurse percusses over the median nerve. The client making a fist and pushing will test strength resistance. The client stretching fingers around a ball will not test for Tinel's sign. Having the client pronate the hand and palpating the radial nerve is not Tinel's sign used for carpal tunnel syndrome diagnosis.

A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include? A.) "This condition is associated with various sports." B.) "Surgery is the only sure way to manage this condition." C.) "Using arm splints will prevent hyperflexion of the wrist." D.) "Ergonomic changes can be incorporated into your workday to reduce stress on your wrist."

Answer: D.) "Ergonomic changes can be incorporated into your workday to reduce stress on your wrist." Rationale: Ergonomic changes, such as adjusting keyboard height, can help clients with carpal tunnel syndrome avoid hyperextension of the wrist. This condition is associated with repetitive tasks such as clerical work, not sports. The condition may be managed with medications, yoga, acupuncture, and wrist (not arm) splints.

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure? A.) Administering large doses of oral antibiotics as ordered B.) Instructing the client to ambulate twice daily C.) Withholding all oral intake D.) Administering large doses of I.V. antibiotics as ordered

Answer: D.) Administering large doses of I.V. antibiotics as ordered Rationale: Treatment of acute osteomyelitis includes large doses of I.V. antibiotics (after blood cultures identify the infecting organism). Surgical drainage may be indicated, and the affected bone is immobilized. The client usually requires I.V. fluids to maintain hydration, but oral intake isn't necessarily prohibited.

Morton neuroma is exhibited by which clinical manifestation? A.) Swelling of the third (lateral) branch of the median plantar nerve B.) High arm and a fixed equinus deformity C.) Diminishment of the longitudinal arch of the foot D.) Inflammation of the foot-supporting fascia

Answer: A.) Swelling of the third (lateral) branch of the median plantar nerve Rationale: Morton neuroma is swelling of the third branch of the median plantar nerve. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Flatfoot is a common disorder in which the longitudinal arch of the foot is diminished. Plantar fasciitis is an inflammation of the foot-supporting fascia.

The nurse is preparing a client for a surgical procedure that will allow visualization of the extent of joint damage of the knee for a client with rheumatoid arthritis and also obtain a sample of synovial fluid. What procedure will the nurse prepare the client for? A.) Open reduction B.) Needle aspiration C.) Arthroplasty D.) Arthroscopy

Answer: D.) Arthroscopy

What clinical manifestation would the nurse expect to find in a client who has had osteoporosis for several years? A.) Bone spurs B.) Diarrhea C.) Increased heel pain D.) Decreased height

Answer: D.) Decreased height

A nurse is caring for an elderly female client with osteoporosis. When teaching the client, the nurse should include information about which major complication? A.) Bone fracture B.) Loss of estrogen C.) Negative calcium balance D.) Dowager's hump

Answer: A.) Bone fracture

Which of the following inhibits bone resorption and promotes bone formation? A.) Calcitonin B.) Estrogen C.) Parathyroid hormone D.) Corticosteroids

Answer: A.) Calcitonin Rationale: Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased in osteoporosis. Estrogen, which inhibits bone breakdown, decreases with aging. On the other hand, parathyroid hormone (PTH) increases with aging, increasing bone turnover and resorption. The consequence of these changes is net loss of bone mass over time. Corticosteroids place patients as risk for developing osteoporosis.

The majority of bone infections are caused by which organism? A.) Staphylococcus aureus B.) Proteus C.) Pseudomonas

Answer: A.) Staphylococcus aureus

What food can the nurse suggest to the client at risk for osteoporosis? A.) Carrots B.) Broccoli C.) Chicken D.) Bananas

Answer: B.) Broccoli

A nurse is caring for a client with eczema. Which medication would be prescribed when an allergy is a factor causing the skin disorder? A.) Dexamethasone B.) Chlorpheniramine C.) Dicloxacillin D.) Bupivacaine

Answer: B.) Chlorpheniramine Rationale: Antihistamines such as chlorpheniramine are frequently prescribed when an allergy is a factor in causing a skin disorder. Antihistamines relieve itching and shorten the duration of allergic reaction. Corticosteroids such as dexamethasone are used to relieve inflammatory or allergic symptoms. Antibiotics such as dicloxacillin are used to treat infectious disorders. Local anesthetics such as bupivacaine are used to relieve minor skin pain and itching.

The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided? A.) "I will lie prone with my legs slightly elevated." B.) "I will bend at the waist when I am lifting objects from the floor." C.) "I will avoid prolonged sitting or walking." D.) "Instead of turning around to grasp an object, I will twist at the waist."

Answer: C.) "I will avoid prolonged sitting or walking." Rationale: The nurse encourages the patient to alternate lying, sitting, and walking activities frequently, and advises the patient to avoid sitting, standing, or walking for long periods.

When describing malignant bone tumors to a group of students, which of the following would the instructor cite as the usual location? A.) Proximal humerus B.) Wrist-hand junction C.) Distal femur around the knee D.) Femur-hip area

Answer: C.) Distal femur around the knee Rationale: Malignant bone tumors usually are located around the knee in the distal femur or proximal fibula; a few are found in the proximal humerus. The wrist-hand junction and femur-hip area are not common sites.

A nurse is teaching a client about preventing osteoporosis. Which teaching point is correct? A.) Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. B.) To prevent fractures, the client should avoid strenuous exercise. C.) The recommended daily allowance of calcium may be found in a wide variety of foods. D.) Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

Answer: C.) The recommended daily allowance of calcium may be found in a wide variety of foods.

The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given? A.) Alendronate B.) Raloxifene C.) Teriparatide D.) Denosumab

Answer: A.) Alendronate Rationale: Alendronate is a bisphosphonate medication. Raloxifene is a selective estrogen receptor modulator. Teriparatide is an anabolic agent, and denosumab is a monoclonal antibody agent.

The nurse is educating a client with low back pain on proper lifting techniques. The nurse recognizes that the education was effective when the client A.) reaches over the head with the arms fully extended. B.) places the load close to the body. C.) uses a narrow base of support. D.) bends at the hips and tightens the abdominal muscles.

Answer: B.) places the load close to the body.

The nurse is educating the patient with low back pain about the proper way to lift objects. What muscle should the nurse encourage the patient to maximize? A.) Gastrocnemius B.) Latissimus dorsi C.) Quadriceps D.) Rectus abdominis

Answer: C.) Quadriceps Rationale: The nurse instructs the patient in the safe and correct way to lift objects using the strong quadriceps muscles of the thighs, with minimal use of weak back muscles (Fig. 42-3).

The client has just been diagnosed with osteomyelitis. What are possible causes of osteomyelitis? Select all that apply. - Trauma, such as penetrating wounds or compound fractures - Vascular insufficiency in clients with diabetes or peripheral vascular disease - Surgical contamination, such as pin sites of skeletal traction - Progressive osteoporosis

Answer: - Trauma, such as penetrating wounds or compound fractures - Vascular insufficiency in clients with diabetes or peripheral vascular disease - Surgical contamination, such as pin sites of skeletal traction

The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response? A.) Decrease in estrogen B.) Increase in calcitonin C.) Decrease in parathyroid hormone D.) Increase of vitamin D

Answer: A.) Decrease in estrogen Rationale: Age related processes that contribute to loss of bone mass and osteoporosis are decreases in estrogen, calcitonin, and vitamin D and an increase in parathyroid hormone.

Which of the following is the only selective estrogen receptor modulator approved for osteoporosis in post menopausal women? A.) Raloxifene B.) Fosamax C.) Forteo D.) Denosumab

Answer: A.) Raloxifene Rationale: Raloxifene is the only selective estrogen receptor modulator (SERM) approved for osteoporosis in post menopausal women as it does not increase the risk of breast or uterine cancer, but it does come with an increased risk of thromboembolism. Fosamax is a bisphosphonate. Forteo is a subcutaneously administered medication that is given one daily for the treatment of osteoporosis. Denosumab has recently been approved for treatment of postmenopausal women with osteoporosis who are at risk for fractures.

A client has experienced increasing pain and progressing inflammation of the hands and feet. The rheumatologist has prescribed NSAID use to treat the condition. What client education is most important for the nurse to address with the use of these medications? A.) common adverse effects B.) dietary restrictions C.) activity restrictions D.) loading-dose schedule

Answer: A.) common adverse effects Rationale: The most common adverse effects of NSAIDs are related to the GI tract: nausea, vomiting, diarrhea, and constipation. GI bleeding, which in some cases is severe, has been reported with the use of these drugs. Use of NSAIDs does not pose significant dietary or activity restrictions nor is there a loading-dose schedule.

During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse? A.) "After age 40, height may show a gradual decrease as a result of spinal compression" B.) "After menopause, the body's bone density declines, resulting in a gradual loss of height." C.) "There may be some slight discrepancy between the measuring tools used." D.) "The posture begins to stoop after middle age."

Answer: B.) "After menopause, the body's bone density declines, resulting in a gradual loss of height."

The nurse is educating a client on home care following removal of a ganglion cyst from the right wrist. Which statement by the client demonstrates that the nurse's teaching has been effective? A.) "If my pain is not relieved I will use a heat pack and take some more medication." B.) "I will leave the dressing on until I follow up with my doctor as scheduled." C.) "If my hand becomes numb and cool I will elevate it above my heart." D.) "I will notify my doctor if I develop redness and purulent drainage for 2 days."

Answer: B.) "I will leave the dressing on until I follow up with my doctor as scheduled." Rationale: The first dressing is changed by the surgeon at a scheduled follow-up appointment. If the hand becomes cool and numb, the client needs to call the surgeon as soon as possible. The surgeon should be notified immediately if redness and purulent drainage develop. Medication should only be used as prescribed. The use of heat may increase swelling, which may increase pain.

A patient has been diagnosed with osteomalacia. What common symptoms does the nurse recognize that correlate with the diagnosis? A.) Bone fractures and kyphosis B.) Bone pain and tenderness C.) Muscle weakness and spasms D.) Softened and compressed vertebrae

Answer: B.) Bone pain and tenderness Rationale: Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. As a result, the skeleton softens and weakens, causing pain, tenderness to touch, bowing of the bones, and pathologic fractures. On physical examination, skeletal deformities (spinal kyphosis and bowed legs) give patients an unusual appearance and a waddling gait.

A client diagnosed with carpal tunnel syndrome (CTS) asks the nurse about numbness in the fingers and pain in the wrist. What is the best response by the nurse? A.) "CTS is a neuropathy that is characterized by bursitis and tendinitis." B.) "CTS is a neuropathy that is characterized by flexion contracture of the fourth and fifth fingers." C.) "CTS is a neuropathy that is characterized by compression of the median nerve at the wrist." D.) "CTS is a neuropathy that is characterized by pannus formation in the shoulder."

Answer: C.) "CTS is a neuropathy that is characterized by compression of the median nerve at the wrist."

On a visit to the family health care provider, a client is diagnosed with a bunion on the lateral side of the great toe at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session? A.) "Bunions are congenital and can't be prevented." B.) "Bunions may result from wearing shoes that are too big, causing friction when the shoes slip back and forth." C.) "Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." D.) "Bunions are caused by a metabolic condition called gout."

Answer: C.) "Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." Rationale: Bunions may be congenital or may be acquired by wearing shoes that are too short or narrow, which increases pressure on the bursa at the metatarsophalangeal joint. Acquired bunions can be prevented. Wearing shoes that are too big may cause other types of foot trauma but not bunions. Gout doesn't cause bunions. Although a client with gout may have pain in the big toe, such pain doesn't result from a bunion.

A client with a musculoskeletal injury is instructed to alter the diet. The objective of altering the diet is to facilitate the absorption of calcium from food and supplements. Considering the food intake objective, which food item should the nurse encourage the client to include in the diet? A.) Red meat B.) Bananas C.) Vitamin D-fortified milk D.) Green vegetables

Answer: C.) Vitamin D-fortified milk

A client visits an orthopedic specialist because of pain beginning in the low back and radiating behind the right thigh and down below the right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between which intervertebral disks? A.) C3, C4, and L1 B.) L1, L2, and L4 C.) L2, L3, and L5 D.) L4, L5, and S1

Answer: D.) L4, L5, and S1 Rationale: The lower lumbar disks, L4-L5 and L5-S1, are subject to the greatest mechanical stress and the greatest degenerative changes. Disk protrusion (herniated nucleus pulposus) or facet joint changes can cause pressure on nerve roots as they leave the spinal canal, which results in pain that radiates along the nerve.

In chronic osteomyelitis, antibiotics are adjunctive therapy in which situation? A.) Wound packing B.) Wound irrigation C.) Vitamin supplements D.) Surgical debridement

Answer: D.) Surgical debridement

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing? A.) Wound packing B.) Wound irrigation C.) Vitamin supplements D.) Surgical debridement

Answer: D.) Surgical debridement Rationale: In chronic osteomyelitis, surgical debridement is used when the wound fails to respond to antibiotic therapy. Wound packing, vitamin supplements, and wound irrigation are not the standard of care when treating chronic osteomyelitis.

A nurse is performing foot care for a client with chronic osteomyelitis and the client asks the nurse about the next treatment. What is the specific treatment for a client with chronic osteomyelitis? A.) Aggressive physical therapy B.) Drainage of localized foci of infection C.) Continued aseptic wound treatment D.) Surgical removal of the sequestrum

Answer: D.) Surgical removal of the sequestrum Rationale: A sequestrectomy, removal of enough involucrum to enable the surgeon to remove the sequestrum, is performed on clients with chronic osteomyelitis. In many cases, sufficient bone is removed to convert a deep cavity into a shallow saucer (saucerization). All dead, infected bone and cartilage must be removed before permanent healing can occur. Aggressive physical therapy is not recommended until healing has occurred. Draining the infection is not sufficient to heal chronic osteomyelitis. Continued wound care is not sufficient to heal the wound.

The nurse is assisting a client with removing shoes prior to an examination and observes that the client has a flexion deformity of several toes on both feet of the proximal interphalangeal (PIP) joints. What can the nurse encourage the client to do? A.) Bind the toes so that they will straighten. B.) Do active range of motion on the toes. C.) Have surgery to fix them. D.) Wear properly fitting shoes.

Answer: D.) Wear properly fitting shoes. Rationale: Hammer toe is a flexion deformity of the PIP joint and may involve several toes and may result from wearing poorly fitting shoes. They will not straighten by binding the toes or doing active range of motion exercises. Surgery is an option but should be discussed with an orthopedic surgeon or podiatrist.