Med Surg - Chapter 50 - Care of Patients with Musculoskeletal Problems

The nurse completes a teaching session on safe drug administration for a patient with Paget's disease taking oral bisphosphonates. Which patient statement indicates a need for further teaching? 1 "I should go to sleep immediately after taking the drug." 2 "I will use chlorhexidine mouth wash to maintain oral hygiene." 3 "I should not undergo any invasive treatment procedure while on the therapy." 4 "I should stop taking this medication 3 months prior to any invasive dental treatment."

1 "I should go to sleep immediately after taking the drug." Oral bisphosphonates can cause stomach upset, inflammation, and erosions of the esophagus. This can be prevented by remaining upright for 30 to 60 minutes after taking the medication. Oral hygiene should be maintained as long as the drug is taken. Patients taking bisphosphonates are more prone to develop osteonecrosis of the jaw, so invasive surgical procedures are to be avoided. The drug should be stopped 3 months prior to any invasive dental treatment to prevent complications.

An enlarged first metatarsal head is known as what? 1 Bunion 2 Hallux valgus 3 Plantar fasciitis 4 Dupuytren contracture

1 Bunion A bunion is an enlarged first metatarsal and is caused by hallux valgus. Dupuytren contracture is a musculoskeletal disorder that affects the hand or part of the hand. Plantar fasciitis is a condition in which the plantar fascia are inflamed. Hallux valgus is a deformity of the foot in which the great toe drifts laterally at the first metatarsophalangeal.

The hallux valgus deformity can cause what other condition? 1 Bunion 2 Corn 3 Callus 4 Dupuytren contracture

1 Bunion Bunions are enlarged first metatarsal heads, caused by hallux valgus. Dupuytren contracture is a deformity of the hand, and hallux valgus affects the foot. Corns are caused by friction and pressure. Calluses are caused by pressure as well.

Which is a key feature of acute osteomyelitis? 1 Fever 2 Foot ulcer 3 Localized pain 4 Sinus tract formation

1 Fever Fever or temperature above 101° F (38.3° C), swelling around the affected area, and erythema of the affected area are some of the key features of acute osteomyelitis. Foot ulcers, localized pain, sinus tract formation, and drainage from the affected area are the key features of chronic osteomyelitis.

Which fingers are affected by Dupuytren contracture? 1 Fourth and fifth fingers 2 Second and fifth fingers 3 Thumb and second finger 4 Second and fourth fingers

1 Fourth and fifth fingers Dupuytren contracture is a musculoskeletal disorder that causes flexion contracture of the fourth and fifth fingers of the hand. Sometimes, the third finger is affected. The thumb and second finger are not affected.

What causes corns? 1 Friction 2 Infection 3 Hammertoe 4 Ingrown nails

1 Friction Friction, as well as pressure, can cause corns. Infections do not cause corns. Hammertoe is a deformity of the foot, but it does not cause corns. Ingrown nails cause infections and hypertrophic ungual labium.

When checking a patient with fractures, a wound, and extensive soft tissue damage for signs of infection, which results indicate that there is no infection present? Select all that apply. 1 Lack of fever 2 Negative wound culture 3 Increased phosphorous level 4 Increased serum calcium level 5 No increase in white blood cell count 6 Decreased erythrocyte sedimentation rate

1 Lack of fever 2 Negative wound culture 5 No increase in white blood cell count No fever, a negative wound culture, and no increase in white blood cell count indicate a lack of infection. During the healing stages, phosphorous and serum calcium levels are often increased because the bone releases these minerals into the bloodstream. This has nothing to do with the presence of an infection. If extensive soft tissue damage is present, the erythrocyte sedimentation rate might be elevated. This indicates inflammation. If both the erythrocyte sedimentation rate and the white blood cell count are elevated, this might indicate an infection.

What are the risk factors for primary osteoporosis? Select all that apply. 1 Parental history of osteoporosis 2 Thin build with low body weight 3 Long-term corticosteroid drug therapy 4 Chronic low calcium and vitamin D intake 5 Immobilization of a limb following a fracture

1 Parental history of osteoporosis 2 Thin build with low body weight 4 Chronic low calcium and vitamin D intake Evidence demonstrates that genetics is a very important contributing factor for primary osteoporosis; 50% to 90% of cases are hereditary. People with a thin build and low body weight have relatively low bone density, which leads to osteoporosis. A diet with decreased calcium and vitamin D intake stimulates the parathyroid gland to produce parathyroid hormone (PTH). PTH triggers the release of calcium from the bony matrix. Vitamin D is required for calcium absorption by the body. Estrogen helps prevent bone loss and postmenopausal patients have estrogen deficiency; long-term corticosteroid drug therapy results in secondary osteoporosis. Immobilization of a limb following a fracture leads to regional osteoporosis.

Where does the nurse expect to find a conical mass, or corn, on the patient's body? 1 Toe 2 Wrist 3 Fingers 4 Shoulder

1 Toe Conical masses are corns, and they are common foot problems. Therefore, the nurse expects to find corns on the toes. Ganglion cysts occur in the wrist. Conical masses do not appear on the shoulder or fingers.

Which finding does the nurse expect to observe in a patient with suspected common chronic osteomyelitis? 1 Ulceration of the skin 2 Erythema of the affected area 3 Constant, localized, and pulsating bone pain 4 Fever; temperature usually above 101° F (38° C)

1 Ulceration of the skin Ulceration of the skin is a feature of chronic osteomyelitis. Erythema of the affected area; fever; and constant, localized, pulsating bone pain are features of acute osteomyelitis.

An 80-year-old patient experiencing severe pain in the lower jaw is diagnosed with acute osteomyelitis. Which symptom may be least likely found? 1 Severe throbbing pain 2 Body temperature of 102°F 3 Swelling of the affected region 4 Erythema of the affected region

2 Body temperature of 102°F Older adults may not have an extreme temperature elevation because of lower core body temperature and a compromised immune system that occurs with normal aging. Acute osteomyelitis is characterized by severe throbbing pain, swelling, and erythema of the affected region.

The patient has a flat, poorly defined mass on the sole of the foot. What does this patient most likely have? 1 Corn 2 Callus 3 Bunion 4 Hypertrophic ungual labium

2 Callus A callus is a flat, poorly defined mass on the sole over a bony prominence caused by pressure. A corn is a painful conical mass. A bunion is the enlargement of the first metatarsal. Hypertrophic ungual labium is the chronic hypertrophy of the nail lip.

The nurse is developing a plan of care for a patient with metastatic bone cancer. What is an appropriate goal of treatment to include in the plan of care for this patient? 1 Reconstruct the bone and aid in bone grafting. 2 Improve the quality of life and promote pain relief. 3 Determine the stage of cancer and extent of bone damage. 4 Cure the cancerous bone, cartilage, and metastatic lesions.

2 Improve the quality of life and promote pain relief. The management of metastatic bone cancer is palliative and not curative; therefore, interventions are aimed at improving the quality of life and promoting pain relief. Determining the stage of cancer and extent of bone damage helps in planning the treatment of bone cancer and its metastatic lesions. Curing cancerous bone, cartilage, and metastatic lesions is of secondary importance in management of metastatic bone cancer; palliation is more important. Reconstruction of bone and bone grafting are surgical interventions of less importance in the palliative management of metastatic bone cancer.

A patient is diagnosed with chronic osteomyelitis. What feature does the nurse expect to assess in the patient? 1 Swelling around the affected area 2 Ulceration resulting in the sinus tract 3 Presence of temperature above 101° F 4 Pulsating pain that worsens with movement

2 Ulceration resulting in the sinus tract Ulceration resulting in the sinus tract is a characteristic feature of chronic osteomyelitis. Acute osteomyelitis is accompanied with fever (a temperature above 101° F). Acute osteomyelitis also features swelling around the affected area and pulsating pain that worsens with movement. Fever, swelling, and erythema are less common in chronic osteomyelitis.

The nurse meets with a patient who reports having a ganglion. Which part of the body will the nurse inspect? 1 Foot 2 Wrist 3 Elbow 4 Thumb

2 Wrist Ganglion cysts occur in the wrist. The thumb, foot, and elbow are subject to other kinds of musculoskeletal problems, but not ganglions.

A patient with bone cancer is scheduled for a right upper extremity amputation. Which statement by the patient's husband indicates an effective coping strategy? 1 "I'll try to limit her visitors." 2 "The family will avoid direct discussion of my wife's amputation." 3 "I'll have to find ways to help my wife focus on positive aspects of her body." 4 "My family will use diversional methods to help her not focus on the amputation."

3 "I'll have to find ways to help my wife focus on positive aspects of her body." Planning to help the patient focus on positive aspects of her body illustrates that the husband is coping with the change in his wife's body image in a positive way. Planning to have the family avoid direct discussion of the amputation does not allow the patient the opportunity to discuss her feelings about the loss of a limb. Visitors could be a source of comfort and may provide a way for the patient to express her feelings, so visitors should not be limited. Using diversional methods to help the patient not focus on the amputation is not an effective coping strategy; it limits the chance for the patient to discuss feelings about the amputation.

After dental work, a female patient taking medications for osteoporosis reports pain, bleeding gums, and halitosis. Upon examination, the bone is found to be exposed. Which medication is the cause for this condition? 1 Estrogen agonist 2 Estrogen antagonists 3 Bisphosphosphonates 4 Calcium supplement drugs

3 Bisphosphosphonates Bisphosphonates are associated with osteonecrosis of the jaw that may cause apoptosis of the osteoclasts in the bone. Estrogen agonist and antagonists act by inhibiting the differentiation of osteoclasts. Calcium supplements do not cause osteonecrosis.

Which is one of the causes of secondary osteoporosis? 1 Older age 2 Current smoking 3 Diabetes mellitus 4 High alcohol intake

3 Diabetes mellitus Secondary osteoporosis may result from medical conditions such as diabetes mellitus, hyperthyroidism, and hyperparathyroidism; long-term drug therapy, such as with corticosteroids; or prolonged immobility. Primary osteoporosis is more common and occurs in postmenopausal women and in men in their 70s to 80s. The risk factors or causes of primary osteoporosis include older age, smoking, and high alcohol intake.

Which part of the body does the hallux valgus deformity affect? 1 Hand 2 Wrist 3 Foot 4 Ankle

3 Foot The hallux valgus deformity is a common foot problem in which the great toe drifts laterally at the first metatarsophalangeal joint. The hallux valgus deformity does not affect the hands, wrists, or ankles.

What complication of osteomyelitis is the most likely to occur? 1 Pathologic fractures 2 Development of malignancies 3 Formation of bone abscesses 4 Secondary arthritic changes

3 Formation of bone abscesses The most common complication of osteomyelitis is the formation of bone abscesses. Infection stimulates the inflammatory response in the bone and the surrounding tissue which leads to necrosis. The necrotic bone forms a sequestrum when it gets separated from the surrounding bone tissue; this sequestrum acts as a focus for ongoing infection and forms a bone abscess. Pathologic fractures, malignant transformation, and secondary arthritic changes are usually seen in osteitis deformans and also with osteomalacia and bone tumors.

Which term is used to describe a round, benign cyst, often found on a wrist or foot joint or tendon? 1 Bunion 2 Sarcoma 3 Ganglion 4 Dupuytren's contracture

3 Ganglion A ganglion is a fluid-filled lump, which can occur near joints or tendons. It is not a cancer. It is most commonly found on wrists or hands. A bunion is a painful swelling on the first joint of the big toe. A sarcoma is a type of cancer that develops from certain tissues, like bone or muscle. Dupuytren's contracture refers to the thickening of the fibrous tissue layer underneath the skin of the palm and fingers.

How is Dowager's hump formed? 1 Lordosis of the spine 2 Scoliosis of the spine 3 Kyphosis of the spine 4 Kyphoscoliosis of the spine

3 Kyphosis of the spine Kyphosis of the spine is the outward curvature of the thoracic vertebrae. Excessive kyphosis leads to the hump-like appearance that is a characteristic manifestation of bone diseases such as osteoporosis. Lordosis is the inward curvature of the lumbar vertebrae, which does not form a hump. Scoliosis is the deviation of vertebral alignment in all dimensions. Kyphoscoliosis is the combination of kyphosis and scoliosis where a hump-like appearance develops.

The nurse is assessing a patient with Ewing's sarcoma. Which finding does the nurse expect to observe? 1 High fever 2 Bradycardia 3 Leukocytosis 4 Migraine headaches

3 Leukocytosis Ewing's sarcoma is a malignant tumor, and the patient may experience systemic manifestations including leukocytosis, anemia, and low-grade fever. Bradycardia and migraine headache are not symptoms of Ewing's sarcoma. A low-grade fever is a systemic manifestation of Ewing's sarcoma.

What is the medical term for the bone disease caused by reduced blood flow to the bones in the joints? 1 Osteomyelitis 2 Osteomalacia 3 Osteonecrosis 4 Osteogenic sarcoma

3 Osteonecrosis Osteonecrosis results from the temporary or permanent loss of blood supply to the bones that are in the joints. Without blood, the bone tissue dies, and ultimately the bone may collapse. Osteomyelitis is the medical term for a bone infection, usually caused by bacteria, viruses, or fungi. Osteomalacia is the softening of the bones and occurs due to a lack of vitamin D. Osteosarcoma or osteogenic sarcoma is the most common type of primary malignant bone tumor.

Which is a priority problem for the older adult patient diagnosed with bone cancer? 1 Reduced mobility related to weakness and fatigue 2 Altered self-esteem related to fear of death and dying 3 Potential for injury related to weakness and drug therapy 4 Pain of a chronic nature related to tumor invasion of other organs

3 Potential for injury related to weakness and drug therapy Older adult patients are more likely to fall and injure themselves because of weakness and the medications that they are prescribed, especially analgesics. Patient problems of altered self-esteem, reduced mobility, and chronic pain are relevant, but are not the priority. The patient's safety comes first.

A patient whose fracture of the right ulnar bone was immobilized in a cast for nearly 8 weeks reports swelling and pain in the right forearm. Why would the patient be advised to undergo bone mineral density (BMD) test? 1 To evaluate for primary osteoporosis 2 To evaluate for primary osteomyelitis 3 To evaluate for secondary osteoporosis 4 To evaluate for secondary osteomyelitis

3 To evaluate for secondary osteoporosis Secondary osteoporosis may result from certain medical conditions, medications, or lifestyle behavior such as prolonged immobilization. Primary osteoporosis occurs due to age-related or idiopathic factors. Osteomyelitis is infection of the bone characterized by infective manifestations such as fever, pus, discharge, and sinus tract formation. Primary and secondary osteomyelitis have similar symptoms.

The nurse is teaching a young patient about ways to prevent osteoporosis in later adulthood. Which information does the nurse provide? 1 "Engage in a weight-loss program." 2 "Avoid exposure to the sun before 10:00 a.m." 3 "Consume a high-protein, low-carbohydrate diet." 4 "Limit the consumption of carbonated beverages."

4 "Limit the consumption of carbonated beverages." The consumption of 40 ounces of carbonated beverages causes calcium loss; patients should limit their intake of carbonated beverages to prevent osteoporosis later in life. People on a high-protein, low-carbohydrate diet like the Atkins diet tend to replace other foods with protein; excessive protein intake increases calcium loss in the urine. Weight-bearing exercise reduces bone resorption and stimulates bone formation; people with low body weight and thin build are predisposed to osteoporosis. Exposure to the sun between 10:00 a.m. and 3:00 p.m. is not recommended; however, exposure to sunlight before 10:00 a.m. is recommended as a good source of vitamin D.

A patient is prescribed the bisphosphonate (BP) alendronate for osteoporosis. What does the nurse teach the patient? 1 "Take the medication only once a month." 2 "Take the medication along with breakfast." 3 "Check liver function before starting the medication." 4 "Take the medication early in the morning with 8 ounces of water."

4 "Take the medication early in the morning with 8 ounces of water." The patient who is prescribed alendronate must take the medication on an empty stomach with 8 ounces of water and wait for 30 to 60 minutes in an upright position, either sitting or standing, before eating or drinking. BPs are associated with esophageal ulcers, especially if the tablet is not swallowed completely. The medication is taken either daily or weekly depending on the dose. Patients with poor renal function, hypocalcemia, or gastroesophageal reflux disease (GERD) must not take BPs. Patients receiving BP therapy by IV need not have a liver function test before starting the medication; however, they must have an oral assessment and preventive dentistry before beginning therapy because this therapy is associated with jaw osteonecrosis.

Which disorder affects the hand or part of the hand? 1 Bunion 2 Hallux valgus 3 Plantar fasciitis 4 Dupuytren contracture

4 Dupuytren contracture Dupuytren contracture is a musculoskeletal disorder that affects the hand or part of the hand. Hallux valgus is a deformity of the foot. A bunion is an enlarged first metatarsal. Plantar fasciitis affects the foot.

Which is a deformity of the hand? 1 Bunion 2 Plantar fasciitis 3 Morton's neuroma 4 Dupuytren's contracture

4 Dupuytren's contracture Dupuytren's contracture is a thickening of the fibrous tissue layer underneath the skin of the palm and fingers. A bunion is a painful swelling on the first joint of the big toe. A sarcoma is a type of cancer that develops from certain tissues, like bone or muscle. Plantar fasciitis is one of the most common causes of heel pain. It involves pain and inflammation of a thick band of tissue, called the plantar fascia, which runs along the bottom of the foot and connects the heel bone to the toes. Morton's neuroma is an injury to the nerve between the toes, which causes thickening and pain. The injury is caused due to the growth of a small tumor in a digital nerve of the foot.

The nurse plans to refer a patient diagnosed with osteoporosis to which community resource? 1 I Can Cope 2 CanSurmount 3 American Bone Society 4 National Osteoporosis Foundation

4 National Osteoporosis Foundation Patients with musculoskeletal problems should be referred to appropriate community resources, like the National Osteoporosis Foundation. The American Bone Society does not actually exist. CanSurmount is a cancer support group geared toward patient and family education. I Can Cope is also a support group for patients with cancer.

Which nursing action is appropriate when a patient requests spiritual guidance during a preoperative assessment? 1 Ask the family to pray for the patient during the procedure 2 Request that the surgeon review the procedure with the patient 3 Tell the patient to contact his or her religious leader after surgery 4 Offer assistance to arrange for a hospital chaplain to talk with the patient before surgery

4 Offer assistance to arrange for a hospital chaplain to talk with the patient before surgery The nurse should offer assistance to arrange for a chaplain to talk with the patient before surgery in this situation. Telling the patient to contact his or her religious leader after the surgery will not solve the patient's immediate concerns. Asking the family to pray for the patient during the procedure does not address the patient's request nor does requesting that the surgeon review the procedure with the patient.

Arrange in the correct order the process of sequestrum formation as it occurs in osteomyelitis. 1. Sequestrum formation 2. Vascular thrombosis 3. Ischemia of bone tissue 4. Stimulation of inflammatory response 5. Release of exudate into the bone tissue 6. Invasion of pathogenic microorganisms

6, 4, 2, 5, 3, 1 Invasion of pathogenic microorganisms stimulates the inflammatory response in bone tissue. Once inflammation is established, there is vascular thrombosis and release of exudate (pus) into bony tissue. Ischemia of bone tissue follows and results in necrotic bone. This area of necrotic bone separates from surrounding bone tissue, and sequestrum is formed.