Musculoskeletal

2. A patient with osteomyelitis has a nursing diagnosis of risk for injury. What is an appropriate nursing intervention for this patient? a. Use careful and appropriate disposal of soiled dressings. b. Gently handle the involved extremity during movement.

2. b. The patient with osteomyelitis is at risk for pathologic fractures at the site of the infection because of weakened, devitalized bone and careful handling of the extremity isnecessary. Careful handling of dressings is necessary to prevent the spread of infection to others but is not related to preventing injury to this patient. Splints may be used to immobilize the limb, range-of-motion (ROM) exercises will be limited because of the possibility of spreading infection, and edema is not a common finding in osteomyelitis.

24. In a patient with a stable vertebral fracture, what should the nurse teach the patient to do? a. Remain on bed rest until the pain is gone. b. Logroll to keep the spine straight when turning.

24. b. The spine should be kept straight by turning the shoulders and hips together (logrolling). This keeps the spine in good alignment until union has been accomplished

27. Which kind of hip fracture is usually repaired with a hip prosthesis? a. Intracapsular

27. a. A hip prosthesis is usually used for intracapsular fractures.

28. An older adult woman is admitted to the emergency department after falling at home. The nurse cautions her not to put weight on the leg after finding what in the patient assessment? d. Shortening and external rotation of the leg

28. d. The classic signs of a hip fracture are shortening of the leg and external rotation accompanied by severe pain at the fracture site and additional injury could be caused by weight bearing on the extremity.

29. A patient with an extracapsular hip fracture is admitted to the orthopedic unit and placed in Buck's traction. The nurse explains to the patient that the purpose of the traction is to do what? c. Reduce pain and muscle spasms before surgery

29. c. Although surgical repair is the preferred method of managing intracapsular and extracapsular hip fractures, initially patients frequently may be treated with skin traction, such as Buck's traction or Russell's traction, to immobilize the limb temporarily and to relieve the painful muscle spasms before surgery is performed.

3. A patient who experienced an open fracture of the humerus 2 weeks ago is having increased pain at the fracture site. To identify a possible causative agent of osteomyelitis at the site, what should the nurse expect testing to include? a. X-rays b. CT scan c. Bone biopsy d. WBC count

3. c. Because large doses of appropriate antibiotics are necessary in the treatment of acute osteomyelitis, it is important to identify the causative microorganism. The definitive way to determine the causative agent is by bone biopsy or biopsy of the soft tissue surrounding the site. The other tests may help to establish the diagnosis but do not identify the causative agent.

30. A patient with a fractured right hip has an anterior open reduction and internal fixation of the fracture. What should the nurse plan to do postoperatively? a. Get the patient up to the chair on the first postoperative day.

30. a. Because the fracture site is internally fixed with pins or plates, the fracture site is stable and the patient is moved from the bed to the chair on the first postoperative day. Ambulation begins on the first or second postoperative day without weight bearing on the affected leg.

31. What should the nurse include in discharge instructions for the patient following a hip prosthesis with a posterior approach? d. Have a family member put on the patient's shoes and socks.

31. d. Patients with hip prostheses with a posterior approach must avoid extreme flexion, adduction, or internal rotation for at least 6 weeks to prevent dislocation of the prosthesis.

32. When preparing a patient for discharge following fixation of a mandibular fracture, the nurse determines that teaching has been successful when the patient says what? c. "I may use a bulk-forming laxative if my liquid diet causes constipation.

32. c. The low-bulk, high-carbohydrate liquid diet and intake of air through a straw required during mandibular fixation often lead to constipation and flatus, which may be relieved with bulk-forming laxatives, prune juice, or ambulation.

33. Priority Decision: Twenty-four hours after a below-the-knee amputation, a patient uses the call system to tell the nurse that his dressing (a compression bandage) has fallen off. What is the first action that the nurse should take? c. Reapply the compression dressing.

33. c. The compression dressing or bandage supports the soft tissues, reduces edema, hastens healing, minimizes pain, and promotes residual limb shrinkage. If the dressing is left off, edema will form quickly and may delay rehabilitation.

35. Priority Decision: An immediate prosthetic fitting during surgery is used for a patient with a traumatic below-theknee amputation. During the immediate postoperative period, what is a priority nursing intervention? a. Monitor the patient's vital signs.

35. a. Because the device covers the residual limb, the surgical site cannot be directly seen and postoperative hemorrhage is not apparent on dressings, requiring vigilant assessment of vital signs for signs of bleeding.

36. Why does a nurse position a patient with an above-the-knee amputation with a delayed prosthetic fitting prone several times a day? a. To prevent flexion contractures

36. a. Flexion contractures, especially of the hip, may be debilitating and delay rehabilitation of the patient with a leg amputation. To prevent hip flexion, the patient should avoid sitting in a chair with the hips flexed or having pillows under the surgical extremity for prolonged periods and the patient should lie on the abdomen for 30 minutes three to four times a day to extend the hip.

37. A patient who had a below-the-knee amputation is to be fitted with a temporary prosthesis. It is most important for the nurse to teach the patient to do what? a. Inspect the residual limb daily for irritation.

37. a. Skin breakdown on the residual limb can prevent the use of a prosthesis so the limb should be inspected every day for signs of irritation or pressure areas. No substances except water and mild soap should be used on the residual limb and range-of-motion (ROM) exercises are not necessary when the patient is using a prosthesis.

4. Following 2 weeks of IV antibiotic therapy, a patient with acute osteomyelitis of the tibia is prepared for discharge from the hospital. The nurse determines that additional instruction is needed when the patient makes which statement? a. "I will need to continue antibiotic therapy for 4 to 6 weeks." b. "I shouldn't bear weight on my affected leg until healing is complete." c. "I can use a heating pad on my lower leg for comfort and to promote healing."

4. c. Activities such as exercise or heat application, which increase circulation and serve as stimuli for the spread of infection, should be avoided by patients with acute osteomyelitis. Oral or IV antibiotic therapy is continued at home for 4 to 6 weeks, weight bearing is contraindicated to prevent pathologic fractures, and notification of the health care provider if increased pain occurs is necessary.

The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding a. reduced joint pain

A Colchicine reduces joint pain in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day during acute gout would increase urine output but would not indicate the effectiveness of colchicine. Elevated serum uric acid would result in increased symptoms. The WBC count might decrease with decreased inflammation but would not increase.

After the nurse has taught a 28-yr-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? a. "I will need to stop drinking so much coffee and soda."

A Dietitians frequently suggest patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management.

A patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of a. sertraline (Zoloft).

A Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? a. Check the patient's prescribed weight-bearing status.

A The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer.

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should a. assess the surgical site for hemorrhage.

A The nurse should monitor for postoperative hemorrhage Because the device covers the residual limb, the surgical site cannot be directly seen and postoperative hemorrhage is not apparent

In which order will the nurse implement these interprofessional interventions prescribed for a patient admitted with acute osteomyelitis with a temperature of 101.2° F? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain blood cultures from two sites. b. Administer dose of gentamicin 60 mg IV. c. Send to radiology for computed tomography (CT) scan of right leg. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever.

A, B, D, C The highest treatment priority for possible osteomyelitis is initiation of antibiotic therapy, but cultures should be obtained before administration of antibiotics. Addressing the discomfort of the fever is the next highest priority. Because the purpose of the CT scan is to determine the extent of the infection, it can be done last.

18. A 70-year-old male presents with back pain, fever, and weight loss. He reports that he had a recent respiratory infection from which he thought he recovered. Tests revealed increased white blood cell count, and a diagnosis of endogenous osteomyelitis was made. The primary organism causing this condition is: a. Staphylococcus aureus

ANS: A Staphylococcus aureus remains the primary microorganism responsible for osteomyelitis.

Which information will the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self-management? b. A gradual increase in daily exercise may help decrease fatigue.

B A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with SEID syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. SEID usually does not progress.

A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first? a. Patient who reports foot pain after hammertoe surgery b. Patient who has not voided 10 hours after a laminectomy

B Difficulty in voiding may indicate damage to the spinal nerves and should be assessed and reported to the surgeon immediately.

A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective? b. "I will begin doing exercises to strengthen and support my back."

B Exercises can help strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back than keeping these joints extended. Sitting for prolonged periods can aggravate back pain

A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care? a. Quadriceps-setting exercises b. Immobilization of the left leg

B Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fracture. Weight-bearing exercise increases the risk for pathologic fractures. Flexion of the affected limb is avoided to prevent contractures.

A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor a. blood glucose. c. erythrocyte count. b. blood pressure.

B Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.

The nurse's discharge teaching for a patient who has had a repair of a fractured mandible will include information about b. how and when to cut the immobilizing wires.

B The jaw will be wired for stabilization, and the patient should know what emergency situations require the wires to be cut to protect the airway.

Which action will the nurse take first when a patient is seen in the outpatient clinic with neck pain? a. Provide information about therapeutic neck exercises. b. Ask about numbness or tingling of the hands and arms.

B The nurse's initial action should be further assessment of related symptoms because cervical nerve root compression will require different treatment than musculoskeletal neck pain.

Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective? b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day."

B The patient lies in the prone position several times daily to prevent flexion contractures of the hip.

A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching? a. How to apply warm packs to the leg to reduce pain b. How to monitor and care for a long-term IV catheter

B The patient will be taking IV antibiotics for several months. The patient will need to recognize signs of infection at the IV site and know how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.

After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action the nurse should take is to a. report the patient's complaint to the surgeon. b. check the chart for preoperative assessment data.

B The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon.

During treatment of the patient with an acute attack of gout, the nurse would expect to administer a. aspirin b. colchicine c. allopurinol (Zyloprim) d. probenecid (Benemid)

B. Colchicine

A patient with gout is treated with drug therapy to prevent future attacks. The nurse teaches the patient that is is the most important to a. avoid all foods high in purine, such as organ meats b. have periodic determination of serum uric acid levels

B. have periodic determination of serum uric acid levels

A patient with an acute attack of gout in the right great toe has a new prescription for probenecid. Which information about the patient's home routine indicates a need for teaching regarding gout management? a. The patient sleeps 8-10 hours each night. b. The patient usually eats beef once a week. c. The patient takes one aspirin a day to prevent angina.

C Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

The nurse is planning care for a patient with hypertension and gout who has a red, painful right great toe. Which nursing action will be included in the plan of care? c. Use a footboard to hold bedding away from the toe.

C Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe, and touching the toe should be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain management.

A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse identifies a need for additional teaching related to health maintenance when the nurse finds that the patient c. is unable to plantar flex the foot on the affected side.

C Foot drop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis.

Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis? a. Ask the patient about any nausea. b. Obtain the patient's oral temperature. c. Review the patient's serum creatinine.

C Gentamicin is nephrotoxic and can cause renal failure as reflected in the patient's serum creatinine

When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine.

C Patients who have facial fractures are at risk for cervical spine injury, and should be treated as if they have a cervical spine injury until this is ruled out

An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to c. keep the head elevated slightly and flex the knees when resting in bed.

C Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms.

Which information will the nurse include when teaching a patient with acute low back pain (select all that apply)? a. Sleep in a prone position with the legs extended. b. Keep the knees straight when leaning forward to pick something up. c. Expect symptoms of acute low back pain to improve in a few weeks. d. Avoid activities that require twisting of the back or prolonged sitting. e. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

C, D, E Acute back pain usually starts to improve within 2 weeks. In the meantime, the patient should use medications such as nonsteroidal antiinflammatory drugs (NSAIDs) or acetaminophen to manage pain and avoid activities that stress the back. Sleeping in a prone position and keeping the knees straight when leaning forward will place stress on the back and should be avoided.

A nurse is teaching a client about her new diagnosis of Systemic Exertion Intolerance Disease, or SEID, and how to manage symptoms. Which of the following would she include in the teaching? Select all that apply a. Plan a carefully graduated exercise program to prevent exacerbation of the disease. b. Rest as often as you feel like you need to. c. NSAIDS can be used to treat headaches, muscle and joint aches, and fever. d. Eat a well-balanced diet, including fiber and fresh, dark colored fruits and vegetables. e. SEID progressively gets worse and is a life-long diagnosis.

Correct answer/s: A, C, & D a. Profound fatigue is one of the main symptoms of SEID. Strenuous exercise can exacerbate the exhaustion. Patients should plan a carefully graduated exercise program because reductions in fatigue have occurred following exercise therapy (p 1548, para 8, 15, p 1549, EBP box). c. NSAIDS can be used to treat headaches, muscle and joint aches, and fever (p 1548, para 14). d. A well balanced diet, including fiber and fresh, dark colored fruits and vegetables are beneficial for their antioxidant action (p 1548, para 15).

When administering medications to the patient with gout, the nurse would recognize which of the following as a treatment for chronic disease? a. Colchicine b. Febuxostat c. Sulfasalazine d. Cyclosporine

Correct answer: b Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for long-term management of hyperuricemia in persons with chronic gout. Acute gouty arthritis is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs).

Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider? d. Temperature 101.4° F (38.6° C)

D An elevated temperature suggests possible osteomyelitis. The other clinical manifestations are

A patient is seen at the outpatient clinic for a sudden onset of inflammation and severe pain in the great toe. A diagnosis of gout is made on the basis of a. a family history of gout b. elevated urine uric acid levels c. elevated serum uric acid levels d. the presence of sodium urate crystals in synovial fluid

D. the presence of sodium urate cystals in synovial fluid

23. What emergency considerations must be included with facial fractures (select all that apply)? a. Airway patency b. Oral examination c. Cervical spine injury

a, c. Airway patency and cervical spinal cord injury are the emergency considerations with facial fractures.

A patient with chronic osteomyelitis has been hospitalized for a surgical debridement procedure. What does the nurse explain to the patient as the rationale for the surgical treatment? a. Removal of the infection prevents the need for bone and skin grafting. b. Formation of scar tissue has led to a protected area of bacterial growth.

b. Chronic infection of the bone leads to formation of scar tissue from the granulation tissue. This avascular scar tissue provides an ideal site for continued microorganism growth and is impenetrable to antibiotics. Surgical debridement is often necessary to remove the poorly vascularized tissue and dead bone and to instill antibiotics directly to the area.

5. During a follow-up visit to a patient with acute osteomyelitis treated with IV antibiotics, the home health nurse is told by the patient's wife that she can hardly get the patient to eat because his mouth is so sore. In assessing the patient's mouth, what should the nurse expect to find? a. A dry, cracked tongue with a central furrow b. White, curdlike membranous lesions of the mucosa

b. One of the most common adverse effects of prolonged and high-dose antibiotic therapy is overgrowth of Candida albicans in the oral cavity and genitourinary tract. These infections are manifested by whitish-yellow, curdlike lesions of the mucosa.

10. What should the nurse teach the patient recovering from an episode of acute low back pain? a. Perform daily exercise as a lifelong routine.

10. a. Proper daily exercise is an important part of the prevention of back injury, with the goal of maintaining mobility and strength in the back. Patients should sit with the knees higher than the hips and should sleep in a side-lying position, with knees and hips bent, or on the back, with a device to flex the hips and knees.

11. A laminectomy and spinal fusion are performed on a patient with a herniated lumbar intervertebral disc. During the postoperative period, which finding is of most concern to the nurse? a. Paralytic ileus b. Urinary incontinence c. Greater pain at the graft site than at the lumbar incision site d. Leg and arm movement and sensation unchanged from preoperative status

11. b. Urinary incontinence following spinal surgery may indicate nerve damage and should be reported to the health care provider. Paralytic ileus is common following surgery and is expected. Pain at the graft site, usually the iliac crest or the fibula, often is more severe than pain at the fused area. Although movement and sensation of the arms and legs should not be more impaired than before surgery, they often are not relieved immediately after surgery.

12. Priority Decision: Before repositioning the patient on the side after a lumbar laminectomy, what should be the nurse's first action? a. Raise the head of the bed 30 degrees. b. Have the patient flex the knees and hips. c. Place a pillow between the patient's legs.

12. c. After spinal surgery, patients are logrolled to maintain straight alignment of the spine at all times, requiring the patient to be turned with a pillow between the legs and moving the body as a unit. The head of the bed is usually kept flat and the legs are extended

14. A young patient with a fractured femur has a hip spica cast applied. While the cast is drying, what should the nurse do? d. Assess the patient frequently for abdominal pain, nausea, and vomiting.

14. d. Complaints of abdominal pain or pressure, nausea, and vomiting are signs of cast syndrome that occur when hip spica casts or body jacket braces are applied too tightly, causing compression of the superior mesenteric artery against the duodenum. T