Chapter 64 - Nursing Management: Musculoskeletal Problems

The nurse provides instructions to a 30-year-old female office worker who has low back pain. Which statement by the patient requires an intervention by the nurse? a. "Acupuncture to the lower back would cause irreparable nerve damage." b. "Smoking may aggravate back pain by decreasing blood flow to the spine." c. "Sleeping on my side with knees and hips bent reduces stress on my back." d. "Switching between hot and cold packs provides relief of pain and stiffness."

A Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic purposes.

The nurse is admitting a patient to the nursing unit with a history of a herniated lumbar disc and low back pain. In completing a more thorough pain assessment, the nurse should ask the patient if which action aggravates the pain? a. Bending or lifting b. Application of warm moist heat c. Sleeping in a side-lying position d. Sitting in a fully extended recliner

A Back pain that is related to a herniated lumbar disc often is aggravated by events and activities that increase the stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Application of moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc

The nurse is caring for a patient hospitalized with exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu? a. Bran muffin b. Scrambled eggs c. Puffed rice cereal d. Buttered white toast

A Each meal should contain one or more sources of fiber, which will reduce the risk of constipation and straining with defecation, which increases back pain. Bran is typically a high-fiber food choice and is appropriate for selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber.

Which nursing intervention is most appropriate when turning a patient following spinal surgery? a. Placing a pillow between the patient's legs and turning the body as a unit b. Having the patient turn to the side by grasping the side rails to help turn over c. Elevating the head of bed 30 degrees and having the patient extend the legs while turning d. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed

A Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort following spinal surgery. Having the patient turn by grasping the side rail to help, elevating the head of the bed, and turning with extended legs or turning the patient's head and shoulders and then the hips will not maintain proper spine alignment and may cause damage.

A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate? a. "IV antibiotics are usually required for several weeks." b. "Oral antibiotics are often required for several months." c. "Surgery is almost always necessary to remove the dead tissue that is likely to be present." d. "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

A The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Surgery may be used for chronic osteomyelitis, which may include debridement of the devitalized and infected tissue and irrigation of the affected bone with antibiotics.

During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? a. The presence of bowed legs b. A measurable loss of height c. Poor appetite and aversion to dairy products d. Development of unstable, wide-gait ambulation

B A gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative it is present. A wide gait is used to support balance and does not indicate osteoporosis.

The nurse prepares to administer IV ibandronate (Boniva) to a 67-year-old woman with osteoporosis. What is a priority laboratory assessment to make before the administration of ibandronate? a. Serum calcium b. Serum creatinine c. Serum phosphate d. Serum alkaline phosphatase

B Ibandronate is a bisphosphonate that is administered IV every 3 months and is administered slowly over 15 to 30 seconds to prevent renal damage. Ibandronate should not be used by patients taking other nephrotoxic drugs or by those with severe renal impairment (defined as serum creatinine above 2.3 mg/dL or creatinine clearance less than 30 mL/min).

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient? a. Nausea and vomiting b. Localized pain and warmth c. Paresthesia in the affected extremity d. Generalized bone pain throughout the leg

B Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized, not generalized throughout the leg.

The 24-year-old male patient who was successfully treated for Paget's disease has come to the clinic with a gradual onset of pain and swelling around the left knee. The patient is diagnosed with osteosarcoma without metastasis. The patient wants to know why he will be given chemotherapy before the surgery. What is the best rationale the nurse should tell the patient? a. The chemotherapy is being used to save your left leg. b. Chemotherapy is being used to decrease the tumor size. c. The chemotherapy will increase your 5-year survival rate. d. Chemotherapy will help decrease the pain before and after surgery.

B Preoperative chemotherapy is used to decrease tumor size before surgery. The chemotherapy will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct chemotherapy after amputation or limb salvage has increased 5-year survival rate in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery.

The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-year-old patient who has low back pain from a herniated lumbar disc. What would be an appropriate nursing intervention to treat this problem? a. Provide gentle ROM to the lower extremities. b. Elevate the head of the bed 20 degrees and flex the knees. c. Place the bed in reverse Trendelenburg with the feet firmly against the footboard. d. Place a small pillow under the patient's upper back to gently flex the lumbar spine.

B The nurse should elevate the head of the bed 20 degrees and flex the knees to avoid extension of the spine and increasing the pain. The slight flexion provided by this position often is comfortable for a patient with a herniated lumbar disc. ROM to the lower extremities will be limited to prevent extremes of spinal movement. Reverse Trendelenburg and a pillow under the patient's upper back will more likely increase pain.

The nurse is planning health promotion teaching for a 45-year-old patient with asthma, low back pain from herniated lumbar disc, and schizophrenia. What does the nurse determine would be the best exercise to include in an individualized exercise plan for the patient? a. Yoga b. Walking c. Calisthenics d. Weight lifting

B The patient would benefit from an aerobic exercise that takes into account the patient's health status and fits the patient's lifestyle. The best exercise is walking, which builds strength in the back and leg muscles without putting undue pressure or strain on the spine. Yoga, calisthenics, and weight lifting would all put pressure on or strain the spine.

The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement? a. "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus." b. "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed." c. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." d. "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management."

C After spinal surgery there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience paralytic ileus and interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery patients often wear a soft or hard cervical collar to immobilize the neck.

The nurse is admitting a patient who complains of a new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc and lower back pain from other causes, what would be the best question for the nurse to ask the patient? a. "Is the pain worse in the morning or in the evening?" b. "Is the pain sharp or stabbing or burning or aching?" c. "Does the pain radiate down the buttock or into the leg?" d. "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?"

C Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve and can be commonly described as traveling through the buttock, to the posterior thigh, or down the leg. This is because the herniated disc causes compression on spinal nerves as they exit the spinal column. Time of occurrence, type of pain, and pain relief questions do not elicit differentiating data.

The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus? a. 22-year-old female with gonorrhea who is an IV drug user b. 48-year-old male with muscular dystrophy and acute bronchitis c. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer d. 68-year-old female with hypertension who had a knee arthroplasty 3 years ago

C Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices such as joint replacements. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.

The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has been successful when the patient selects which highest-calcium meal? a. Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice b. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple c. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk d. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

C The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium, but not as much as the sardines, yogurt, and milk.

The nurse has reviewed proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. Which statement made by the patient indicates a need for further teaching? a. "I should sleep on my side or back with my hips and knees bent." b. "I should exercise at least 15 minutes every morning and evening." c. "I should pick up items by leaning forward without bending my knees." d. "I should try to keep one foot on a stool whenever I have to stand for a period of time."

C The patient should avoid leaning forward without bending the knees. Bending the knees helps to prevent lower back strain and is part of proper body mechanics when lifting. Sleeping on the side or back with hips and knees bent and standing with a foot on a stool will decrease lower back strain. Back strengthening exercises are done twice a day once symptoms subside.

Before discharge from the same-day surgery unit, instruct the patient who has had a surgical correction of bilateral hallux valgus to a. rest frequently with the feet elevated. b. soak the feet in warm water several times a day. c. expect the feet to be numb for the next few days. d. expect continued pain in the feet, since this is not uncommon.

Correct answer: a After surgical correction of bilateral hallux valgus, the feet should be elevated with the heel off the bed to help reduce discomfort and prevent edema.

A patient has been diagnosed with osteosarcoma of the humerus. He shows an understanding of his treatment options when he states a. "I accept that I have to lose my arm with surgery." b. "The chemotherapy before surgery will shrink the tumor." c. "This tumor is related to the melanoma I had 3 years ago." d. "I'm glad they can take out the cancer with such a small scar."

Correct answer: b Rationale: A patient with osteosarcoma usually has preoperative chemotherapy to decrease tumor size before surgery. As a result, limb-salvage procedures, including a wide surgical resection of the tumor, are being used more often. Osteosarcoma is a primary bone tumor that is extremely aggressive and rapidly metastasizes to distant sites.

In caring for a patient after a spinal fusion, the nurse would immediately report to the physician which patient symptom? a. The patient experiences a single episode of emesis. b. The patient is unable to move the lower extremities. c. The patient is nauseated and has not voided in 4 hours. d. The patient complains of pain at the bone graft donor site.

Correct answer: b Rationale: After spinal fusion surgery, the nurse should frequently monitor peripheral neurologic signs. Movement of the arms and legs and assessment of sensation should be unchanged in comparison with the preoperative status. These assessments are usually repeated every 2 to 4 hours during the first 48 hours after surgery, and findings are compared with those of the preoperative assessment. Paresthesias, such as numbness and tingling sensation, may not be relieved immediately after surgery. The nurse should document any new muscle weakness or paresthesias and report this to the surgeon immediately.

You are teaching a patient with osteopenia. What is important to include in the teaching plan? a. Lose weight. b. Stop smoking. c. Eat a high-protein diet. d. Start swimming for exercise.

Correct answer: b Rationale: Patients with osteopenia should be instructed to quit smoking in order to decrease loss of bone mass.

The nurse's responsibility for a patient with a suspected disc herniation who is experiencing acute pain and muscle spasms is a. encouraging total bed rest for several days. b. teaching the principles of back strengthening exercises. c. stressing the importance of straight-leg raises to decrease pain. d. promoting the use of cold and hot compresses and pain medication.

Correct answer: d Rationale: If the acute muscle spasms and accompanying pain are not severe and debilitating, the patient may be treated on an outpatient basis with nonsteroidal antiinflammatory drugs (NSAIDs; e.g., acetaminophen) and muscle relaxants (e.g., cyclobenzaprine [Flexeril]). Massage and back manipulation, acupuncture, and the application of cold and hot compresses may help some patients. Severe pain may necessitate a brief course of opioid analgesics. A brief period (1 to 2 days) of rest at home may be necessary for some people; most patients do better with a continuation of their regular activities. Prolonged bed rest should be avoided. All patients during this time should refrain from activities that aggravate the pain, including lifting, bending, twisting, and prolonged sitting.

Which individuals would be at high risk for low back pain (select all that apply)? a. A 63-year-old man who is a long-distance truck driver b. A 36-year-old 6 ft, 2 in construction worker who weighs 260 lb c. A 28-year-old female yoga instructor who is 5 ft, 6 in and weighs 130 lb d. A 30-year-old male nurse who works on an orthopedic unit and smokes e. A 44-year-old female chef with prior compression fracture of the spine

Correct answers: a, b, d, e Rationale: .Risk factors associated with low back pain include a lack of muscle tone and excess body weight, stress, poor posture, cigarette smoking, pregnancy, prior compression fractures of the spine, spinal problems since birth, and a family history of back pain. Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and prolonged periods of sitting are also associated with low back pain. Low back pain is most often caused by a musculoskeletal problem. The causes of low back pain of musculoskeletal origin include (1) acute lumbosacral strain, (2) instability of the lumbosacral bony mechanism, (3) osteoarthritis of the lumbosacral vertebrae, (4) degenerative disc disease, and (5) herniation of an intervertebral disc. Health care personnel are at high risk for the development of low back pain. Lifting and moving patients, excessive time being stooped over or leaning forward, and frequent twisting can result in low back pain.

A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) a. "The beads are used to directly deliver antibiotics to the site of the infection." b. "There are no effective oral or IV antibiotics to treat most cases of bone infection." c. "This is the safest method of delivering long-term antibiotic therapy for a bone infection." d. "The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." e. "The ischemia and bone death that occur with osteomyelitis are impenetrable to IV antibiotics."

Correct answers: a, d Rationale: Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of IV and oral antibiotics. Antibiotic-impregnated polymethylmethacrylate bead chains may be implanted during surgery to aid in combating the infection.

The nurse cares for a 58-year-old woman with breast cancer who is admitted for severe back pain related to a compression fracture. The patient's laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms will the nurse expect the patient to exhibit? a. Anxiety, irregular pulse, and weakness b. Muscle stiffness, dysphagia, and dyspnea c. Hyperactive reflexes, tremors, and seizures d. Nausea, vomiting, and altered mental status

D Breast cancer can metastasize to the bone. Vertebrae are a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium levels result as calcium is released from damaged bones. Normal serum calcium is between 8.6 to 10.2 mg/dL. Clinical manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Other manifestations include weakness, depressed reflexes, anorexia, bone pain, fractures, polyuria, dehydration, and nephrolithiasis. Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include muscle stiffness, dysphagia, and dyspnea.

A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? a. Ambulate the patient to the bathroom every 2 hours. b. Ask the patient about preferred activities to relieve boredom. c. Allow the patient to dangle legs at the bedside every 2 to 4 hours. d. Perform frequent position changes and range-of-motion exercises.

D The patient is at risk for atelectasis of the lungs and for contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion (ROM) exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest, and dangling the legs every 2 to 4 hours may be too painful. The priority is position changes and ROM exercises.

The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? a. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. b. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. c. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. d. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

D The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements and/or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer.

When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching about this disorder? a. Prolonged bed rest will be used to decrease fatigue. b. An orthotic jacket will limit mobility and may contribute to deformity. c. Continuous positive airway pressure will be used to facilitate sleeping. d. Remain active to prevent skin breakdown and respiratory complications.

D With muscular dystrophy, it is important for the patient to remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP) is used as respiratory function decreases, before mechanical ventilation is needed to sustain respiratory function.