NUR 303 - Chapter 42: Management of Patients With Musculoskeletal Disorders

For a client with osteoporosis, the nurse should provide which dietary instruction?

"Eat more dairy products to increase your calcium intake." Osteoporosis causes a severe, general reduction in skeletal bone mass. To offset this reduction, the nurse should advise the client to increase calcium intake by consuming more dairy products, which provide about 75% of the calcium in the average diet. None of the other options would stop osteoporosis from worsening.

The nurse is caring for the client with chronic osteomyelitis of the jaw with a draining wound. Which nursing diagnosis is appropriate for the client? Select all that apply.

- Acute pain - Disturbed body image - Imbalanced nutrition: less than body requirements Pain is a priority problem for the client with osteomyelitis that can interfere with mobility of joint. In this situation, the client's jaw is the site of infection. Pain in this location can interfere with nutritional intake of the individual. Chronic osteomyelitis presents with a nonhealing ulcer over the infected bone with a connecting sinus that will intermittently and spontaneously drain pus. A draining ulcer on the face can make the individual very self-conscious about appearance, leading to disturbed body image. This client is not at risk for injury or ineffective airway clearance.

A provider asks the nurse to teach a patient with low back pain how to sit in order to minimize pressure on the spine. Which of the following teaching points would the nurse include? Select all that apply.

- Sit in a straight-backed chair with arm rests. - Avoid hip extension. - Place feet flat on the floor. - Sit with the buttocks "tucked under." All choices are correct, except that a soft pillow support is recommended to eradicate the hollow of the back. Refer to Box 41-2 in the text.

A client with osteoporosis is prescribed calcitonin (Miacalcin) 100 units subcutaneously. The medication is available 200 units per ml. How many milliliters will the nurse administer to the client?

0.5 100 units x 1 ml/200 units = 0.5 ml.

A 65-year-old woman's X-rays reveal a diagnosis of osteoporosis. The nurse advises the woman that the radiolucency seen in the bones indicates a minimal level of demineralization of about:

25% Demineralization seen on X-rays occurs when bone loss of 25% to 40% occurs.

A patient comes back to the clinic with a continued complaint of back pain. What time frame does the nurse understand constitutes "chronic pain"?

3 months The typical patient reports either acute back pain (lasting fewer than 3 months) or chronic back pain (3 months or longer without improvement) and fatigue.

A client with diabetes punctured his foot with a broken acorn in the yard. Within a week, the client developed osteomyelitis of the foot. The client was admitted for IV antibiotic therapy. How long does the nurse anticipate the client will receive IV antibiotics?

3 to 6 weeks Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for 3 to 6 weeks. Oral antibiotics then follow for as long as 3 months.

A client with suspected osteomalacia has a fractured tibia and fibula. What test would give a definitive diagnosis of osteomalacia?

A bone biopsy A definitive diagnosis is obtained by bone biopsy. Radiographic studies demonstrate demineralization of the bone. A bone scan detects increased and decreased areas of bone metabolism. Alkaline phosphatase levels are detected from a blood sample.

When reviewing the history of a female client with a ganglion cyst, which factor would the nurse identify as most likely contributing to the client's current condition?

Age below 50 years Ganglion cysts form through defects in the tendon sheath or joint capsule and occur most commonly in women younger than 50 years of age. Being a softball pitcher would increase the client's risk for epicondylitis. Employment as a cashier would be a possible risk factor for carpal tunnel syndrome. Recurrent dislocations are the result of insufficient collagen deposits during the repair stage of a dislocation.

A nurse is caring for an elderly female client with osteoporosis. When teaching the client, the nurse should include information about which major complication?

Bone fracture Bone fracture is a major complication of osteoporosis; it results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause — not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance isn't a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

Which common problem of the upper extremity results from entrapment of the median nerve at the wrist?

Carpal tunnel syndrome Carpal tunnel syndrome is commonly due to repetitive hand activities. A ganglion is a collection of gelatinous material near the tendon sheaths and joints that appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. Dupuytren contracture is a slowly progressive contracture of the palmar fascia. Impingement syndrome is associated with the shoulder and may progress to a rotator cuff tear.

Which assessment findings would the nurse expect in the client with osteomalacia?

Column B Osteomalacia is characterized by decreased serum calcium and phosphorus and elevated alkaline phosphatase levels.

Which assessment findings would the nurse expect to find in the client with osteomyelitis?

Column B Osteomyelitis is characterized by elevated white blood cell count and erythrocyte sedimentation rate.

To help prevent osteoporosis, what should a nurse advise a young woman to do?

Consume at least 1,000 mg of calcium daily. To help prevent osteoporosis, the nurse should encourage the client to consume at least the recommended daily allowance (RDA) of calcium. Before menopause, the RDA is 1,000 mg; after menopause, it's 1,500 mg. Because osteoporosis affects all bones, avoiding trauma to the affected bone only is inappropriate. Using a firm mattress and keeping the uric acid level within the normal range don't relate to osteoporosis. The nurse should encourage a client with ankylosing spondylitis to sleep on a firm mattress. The nurse should advise a client with gouty arthritis to keep the serum uric acid level in the normal range.

The nurse notes that the client's left great toe deviates laterally. This finding would be recognized as which condition?

Hallux valgus Hallux valgus is commonly referred to as a bunion. Hammertoes are usually pulled upward. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. The client with flatfoot demonstrates a diminished longitudinal arch of the foot.

During a routine physical examination of a client, the nurse observes a flexion deformity of the promixal interphalangeal (PIP) joint of two toes on the right foot. The nurse documents this finding as which of the following?

Hammer toe Hammer toe is a flexion deformity of the proximal interphalangeal (PIP) joint and may involve several toes. Mallet toe is a flexion deformity of the distal interphalangeal joint (DIP), and also can affect several toes. Hallux valgus, also called a bunion, is a deformity of the great (large) toe at its metatarsophalangeal joint.

A female client is at risk for developing osteoporosis. Which action will reduce the client's risk?

Initiating weight-bearing exercise routines Performing weight-bearing exercise increases bone health. A sedentary lifestyle increases the risk of developing osteoporosis. Estrogen is needed to promote calcium absorption. The recommended daily intake of calcium is 1,000 mg, not 300 mg.

Which of the following classic symptoms would the nurse assess for to detect the development of plantar fasciitis?

Morning heel pain Plantar fasciitis is characterized by heel pain.

Which of the following is the most common and most fatal primary malignant bone tumor?

Osteogenic sarcoma (osteosarcoma) Osteogenic sarcoma (osteosarcoma) is the most common and most often fatal primary malignant bone tumor. Benign primary neoplasms of the musculoskeletal system include osteochondroma, enchondroma, and rhabdomyoma.

Which condition is a metabolic bone disease characterized by inadequate mineralization of bone?

Osteomalacia Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Osteoporosis is characterized by reduction of total bone mass and a change in bone structure that increases susceptibility to fracture. Osteomyelitis is an infection of bone that comes from extension of soft-tissue infection, direct bone contamination, or hematogenous spread. Osteoarthritis (OA), also known as degenerative joint disease, is the most common and frequently disabling of the joint disorders. OA affects the articular cartilage, subchondral bone, and synovium.

Which of the following presents with an onset of heel pain with the first steps of the morning?

Plantar fasciitis Plantar fasciitis, an inflammation of the foot-supporting fascia, present as an acute onset of heal pain experienced with the first steps in the morning. Hallux valgus (commonly called a bunion) is a deformity in which the great toe deviates laterally. Morton's neuroma is a swelling of the third (lateral) branch of the median plantar nerve. A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm compressible cystic swelling, usually on the dorsum of the wrist.

A 70-year-old client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis, which objective is most appropriate?

Promoting weight-bearing exercises When the mechanical stressors of weight bearing are absent, disuse osteoporosis can occur. Therefore, if the client does weight-bearing exercises, disuse complications can be prevented. Maintaining protein and vitamins levels is important, but neither will prevent osteoporosis. ROM exercises will help prevent muscle atrophy and contractures.

Which term refers to a disease of a nerve root?

Radiculopathy 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.

A client is diagnosed with osteomyelitis. This is most commonly caused by which of the following?

Staphylococcus aureus Staphylococcus aureus causes over 50% of bone infections. Other organisms include Proteus vulgaris and Pseudomonas aeruginosa, as well as E. coli.

The nurse advises a patient that the best position to ease low back pain is:

Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees. Lumbar flexion is increased by elevating the head and thorax 30 degrees 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. A prone position should be avoided because it accentuates lordosis (inward curvature of the spine).

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?

Surgical debridement 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 planning discharge teaching regarding exercise for a client at risk for osteoporosis. Which of the following exercises would be appropriate?

Walking Weight-bearing exercises should be incorporated into the client's lifestyle activities.

Which is not a risk factor for osteoporosis?

being male Being male is not considered a risk factor. Some of the risk factors for osteoporosis are being a small-framed, thin White or Asian woman; being postmenopausal; family history; inactivity; chronic low calcium intake; and excessive caffeine or tobacco use.

A 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?

common adverse effects 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.

Which of the following inhibits bone resorption and promotes bone formation?

Calcitonin 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.

Which of the following was formerly called a bunion?

Hallux valgus Hallux valgus (commonly called a bunion) is a deformity in which the great toe deviates laterally. Plantar fasciitis, an inflammation of the foot-supporting fascia, present as an acute onset of heel pain experienced with the first steps in the morning. Morton's neuroma is a swelling of the third (lateral) branch of the median plantar nerve. A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm compressible cystic swelling, usually on the dorsum of the wrist.

The client presents to the emergency department with fever, chills, restlessness, and limited movement of a fractured jaw. The nurse interprets these findings as indicating which of the following complications?

Osteomyelitis Clinical manifestations of osteomyelitis include signs and symptoms of sepsis and localized infection.

A client with osteoporosis is prescribed a selective estrogen receptor modifier (SERM) as treatment. The nurse would identify which drug as belonging to this class?

Raloxifene An example of a selective estrogen receptor modifier (SERM) is raloxifene (Evista). Alendronate is a biphosphonate; calcium gluconate is an oral calcium preparation; tamoxifen is an antiestrogen agent.

A patient is evaluated for a diagnosis of Paget's disease. Which of the following is a diagnostic finding for this disease?

Alkaline phosphate of 165 IU/L An elevated serum alkaline phosphatase concentration reflects increased osteoblastic activity.

A client has been prescribed alendronate for the prevention of osteoporosis. Which is the highest priority nursing intervention associated with the administration of the medication?

Have the client sit upright for at least 30 minutes following administration While all interventions are appropriate, the highest priority is having the client sit upright for 60 minutes following administration of the medication. This will prevent irritation and potential ulceration of the esophagus. The client should have adequate intake of vitamin D and obtain yearly dental exams. The concurrent use of corticosteroids and alendronate is link to a complication of osteonecrosis.

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

places the load close to the body. Instructions for the client with low back pain should include that, when lifting, the client should avoid overreaching. The client should also keep the load close to the body, bend the knees, and tighten the abdominal muscles; use a wide base of support; and use a back brace to protect the back. Bending at the hips increases the strain on the back muscles when lifting.

A patient is having low back pain. What position can the nurse suggest to relieve this discomfort?

Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees A medium to firm, nonsagging 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 nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct?

The recommended daily allowance of calcium may be found in a wide variety of foods. Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary.

An older adult female has a bone density test that reveals severe osteoporosis. What does the nurse understand can be a problem for this client due to the decrease in bone mass and density?

Compression fractures In osteoporosis, loss of bone substance exceeds bone formation. The total bone mass and density is reduced, resulting in bones that become progressively porous, brittle, and fragile. Compression fractures of the vertebrae are common. Diabetes, hypertension, and cardiac disease may occur in response to the aging process but are not the result of osteoporosis.

A group of students are reviewing information about osteoporosis in preparation for a class discussion. The students demonstrate a need for additional review when they state which of the following as a risk factor?

Hypothyroidism Factors associated with an increased risk for osteoporosis include: family history of osteoporosis, chronic low calcium intake, excessive intake of caffeine, tobacco use, Cushing's syndrome, prolonged use of high doses of corticosteroids, prolonged periods of immobility, hyperthyroidism, hyperparathyroidism, eating disorders, malabsorption syndromes, breast cancer (especially if treated with chemotherapy that suppresses estrogen, excluding Tamoxifen, which may reduce the risk of fractures), renal or liver failure, alcoholism, lactose intolerance, and dietary deficiency of vitamin D and calcium.

Which of the following diagnostics confirms Paget's disease?

X-ray X-rays confirm the diagnosis of Paget's disease. Local areas of demineralization and bone overgrowth produce characteristic mosaic patterns and irregularities. Bone scans demonstrate the extent of the disease. A bone biopsy may aid in the differential diagnosis.

A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include?

"Ergonomic changes can be incorporated into your workday to reduce stress on your wrist." 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.

To confirm a diagnosis of low back pain, which of the following diagnostic procedures would be ordered to rule out the presence of a tumor?

Bone scan A bone scan is the preferred diagnostic procedure to disclose tumors in a patient with low back pain.

The client has just been diagnosed with osteomyelitis. Osteomyelitis is an infection of the bone, resulting in limited blood supply to the bone, inflammation of and pressure on the tissue, bone necrosis, and formation of new bone around devitalized bone tissue. 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 The following are all causes of osteomyelitis: trauma, such as penetrating wounds or compound fractures; vascular insufficiency in clients with diabetes or peripheral vascular disease; and surgical contamination, such as pin sites of skeletal traction. Osteoporosis is not a cause of osteomyelitis.

Which suggestion would be most important to give a client who has a mild case of bunions?

Don proper footwear. The most important instruction a nurse should give clients with bunions or hammer toe is to don proper footwear. Low-heeled, well-fitted shoes are recommended. Regular use of analgesics is not necessary for bunions if pain is not severe and the client has little or no difficulty. The client need not avoid strenuous exercise, running, or foot creams if the footwear is appropriate.

Lifestyle risk factors for osteoporosis include

lack of exposure to sunshine. Lifestyle risk factors for osteoporosis include lack of exposure to sunshine, a diet low in calcium and vitamin D, cigarette smoking, consumption of alcohol and/or caffeine, and lack of weight-bearing exercise. Lack of weight-bearing exercise, not aerobic exercise, is a lifestyle risk factor for osteoporosis. A diet low in calcium and vitamin D, not a low-protein, high-fat diet, is a lifestyle risk factor for osteoporosis. An estrogen deficiency or menopause is an individual risk factor for osteoporosis. Other individual risk factors include female gender, non-Hispanic white or Asian race, increased age, low weight and body mass index, family history of osteoporosis, low initial bone mass, and contributing coexisting medical conditions and medications.

During a routine physical examination on a 75-year-old 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?

"After menopause, the body's bone density declines, resulting in a gradual loss of height." The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.

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?

"I will avoid prolonged sitting or walking." 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.

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?

Alendronate Alendronate is a bisphosphonate medication. Raloxifene is a selective estrogen receptor modulator. Terparatide is an anabolic agent, and denosumab is a monoclonal antibody agent.

Which medication classification is prescribed when allergy is a factor causing the skin disorder?

Antihistamines Antihistamines are frequently prescribed when an allergy is a factor in causing the skin disorder. They relieve itching and shorten the duration of allergic reaction. Corticosteroids are used to relieve inflammatory or allergic symptoms. Antibiotics are used to treat infectious disorders. Local anesthetics are used to relieve minor skin pain and itching.

What food can the nurse suggest to the client at risk for osteoporosis?

Broccoli Calcium is important for the prevention of osteoporosis. Broccoli is high in calcium.

When performing a physical assessment of a client, the client reports numbness, tingling, and pain when the nurse percusses lightly over the median nerve. The nurse recognizes that this finding is consistent with:

Carpal tunnel syndrome Tinel's sign (numbness, tingling, and pain in response to light percussion over the median nerve) is a positive finding for carpal tunnel syndrome.

Which group is at the greatest risk for osteoporosis?

Caucasian women Small-framed, nonobese Caucasian women are at greatest risk for osteoporosis. Asian women of slight build are at risk for low peak bone mineral density. African American women, who have a greater bone mass than Caucasian women, are less susceptible to osteoporosis. Men have a greater peak bone mass and do not experience sudden estrogen reduction.

Which of the following clinical manifestations would the nurse expect to find in a client who has had osteoporosis for several years?

Decreased height Clients with osteoporosis become shorter over time.

A physician prescribes raloxifene to a hospitalized client. The client's history includes a right hip fracture, hysterectomy, deep vein thrombosis, and hypertension. Which action by the nurse demonstrates safe nursing care?

Holding the raloxifene and notifying the physician Raloxifene is contraindicated in clients with a history of deep vein thrombosis. The nurse should hold the medication and notify the physician. Raloxifene can be given without regard to food or time of day. Raloxifene is a selective estrogen receptor modulation medication. Sitting upright for 30-60 minutes is indicated with drugs classified as bisphosphonates.

Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes?

Lower lumbar The lower lumbar disks, L4 to L5 and L5 to S1, are subject to the greatest mechanical stress and greatest degenerative changes.

Morton neuroma is exhibited by which clinical manifestation?

Swelling of the third (lateral) branch of the median plantar nerve 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.

A nurse is performing discharge teaching for an elderly client with osteoporosis. Which instruction about taking a calcium supplement should the nurse include?

Take the supplement with meals or with orange juice. Calcium supplements, such as Caltrate or Citracal, are over-the-counter medications. They should be taken with meals or with a beverage high in vitamin C.

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?

Vitamin D-fortified milk The nurse should advise the client to include dietary sources of vitamin D, such as fatty fish, vitamin D-fortified milk, and cereals. These foods protect against bone loss and decrease the risk of fracture by facilitating the absorption of calcium from food and supplements. Red meat, bananas, and green vegetables do not facilitate calcium absorption from food and supplements.

A client has come to the clinic with foot pain. The physician has described the client's condition as a flexion deformity of the proximal interphalangeal joint. What is the name of this disorder?

hammer toe Hammer toe is a flexion deformity of the proximal interphalangeal joint. Mallet toe is a flexion deformity of the distal interphalangeal joint. Bunion is a deformity of the great toe at its metatarsophalangeal joint. Heberden's nodes are bony enlargements of the distal interphalangeal joints.

The nurse is reviewing the medication administration record of the client. Which of the following medications would lead the nurse to suspect that the client is at risk for osteoporosis?

raloxifene (Evista) Raloxifene (Evista) is used for the prevention and treatment of osteoporosis.

The client diagnosed with osteosarcoma is scheduled for a surgical amputation. Which nursing diagnosis would be a priority for this client compared with other surgical clients?

Disturbed body image Amputation of a body part can result in disturbances in body image.

A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include?

"Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars." Falls in the home cause most injuries among the elderly. Elderly clients should take measures to decrease the clutter that can contribute to falls, such as removing objects such as throw rugs from the floor. Elderly clients should also install grab bars in the shower and next to the toilet. The threat of fire makes burglar bars on every window impractical.

The nurse is caring for the client with chronic osteomyelitis of the jaw with a draining wound. Which client goal is a priority for the client?

- The client will experience a tolerable level of pain. - The client will demonstrate wound care. - The client will maintain adequate nutritional intake. Pain is a priority problem for the client with osteomyelitis, and it can interfere with mobility of joint. In this situation, the client's jaw is the site of infection. Pain in this location can interfere with nutritional intake of the individual. Chronic osteomyelitis presents with a nonhealing ulcer over the infected bone with a connecting sinus that will intermittently and spontaneously drain pus. The client will need to be able to provide wound care in the home setting. Remaining free from injury and maintaining an effective airway clearance are not priority goals for the client.

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?

Arthroscopy Arthroscopic examination may be carried out to visualize the extent of joint damage as well as to obtain a sample of synovial fluid. An open reduction would be used for the treatment of a fracture. Needle aspiration will not allow visualization of the joint damage but will allow obtaining the sample of synovial fluid. Arthroplasty is the restructure of the joint surface after diagnosis is made.

When describing malignant bone tumors to a group of students, which of the following would the instructor cite as the usual location?

Distal femur around the knee 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.

Which of the following diagnostics are used to evaluate spinal nerve root disorders (radiculopathies)?

Electromyogram An electromyogram and nerve conduction studies are used to evaluate spinal nerve toot disorders (radiculopathies) for patients with low back pain. A bone scan may disclose information about infections, tumors, and bone marrow abnormalities. A computed tomography scan is useful in identifying underlying problems, such as obscure soft tissue lesions adjacent to the vertebral column and problems of vertebral disks. Magnetic resonance imaging permits visualization of the nature and location of spinal pathology.

A physician diagnoses primary osteoporosis in a client who has lost bone mass. In this metabolic disorder, the rate of bone resorption accelerates while bone formation slows. Primary osteoporosis is most common in:

elderly postmenopausal women. Although the cause of primary osteoporosis is unknown, an important contributing factor may be faulty protein metabolism resulting from estrogen deficiency and a sedentary lifestyle. Typically, these conditions occur in elderly postmenopausal women.

On a visit to the family physician, 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?

"Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." 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.

Which are true about Lyme disease? Select all that apply.

- If untreated, the disease moves through three stages. - Early stage symptoms may include a red macule or papule at the site of the tick bite, a characteristic bullseye rash with round rings around the center, headache, neck stiffness, pain, fever, chills, malaise, nausea, vomiting, and sore throat. - Cardiac and neurologic symptoms occur midstage, followed by arthritis and joint problems. If untreated, the disease moves through three stages. Early stage symptoms may include a red macule or papule at the site of the tick bite, a characteristic bullseye rash with round rings around the center, headache, neck stiffness, pain, fever, chills, malaise, nausea, vomiting, and sore throat. Cardiac and neurologic symptoms occur midstage, followed by arthritis and joint problems. There is no kidney involvement with Lyme disease.

What term refers to a flexion deformity caused by a slowly progressive contracture of the palmar fascia?

Dupuytren contracture Dupuytren disease results in a slowly progressive contracture of the palmar fascia, called Dupuytren contracture. A callus is a discretely thickened area of skin that has been exposed to persistent pressure or friction. A hammertoe is a flexion deformity of the interphalangeal joint, which may involve several toes. Hallux valgus is a deformity in which the great toe deviates laterally.

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?

Wear properly fitting shoes. 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.

The nurse is educating a group of women on the prevention of osteoporosis. The nurse recognizes the education as being effective when the group members make which statement?

"We need an adequate amount of exposure to sunshine." The only accurate statement is related to getting an adequate amount of exposure to sunshine. Aerobic exercise, such as swimming, does not prevent osteoporosis. The exercise needs to be weight bearing. A diet low in calcium and high in phosphorus will increase the risk forosteoporosis. Estrogen deficiency is linked to decreased bone mass.

The nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching?

"You will receive IV antibiotics for 3 to 6 weeks." Treatment of osteomyelitis requires IV antibiotics for 3 to 6 weeks.

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?

Administering large doses of I.V. antibiotics as ordered 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.

A patient is diagnosed with osteogenic sarcoma. What laboratory studies should the nurse monitor for the presence of elevation?

Alkaline phosphatase Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma or bone metastasis. Hypercalcemia is also present with bone metastases from breast, lung, or kidney cancer. Symptoms of hypercalcemia include muscle weakness, fatigue, anorexia, nausea, vomiting, polyuria, cardiac dysrhythmias, seizures, and coma. Hypercalcemia must be identified and treated promptly.

The nurse recognizes that the client with osteomyelitis is at risk for:

Bone abscess formation Bone abscess formation is a potential complication of osteomyelitis.

Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing bone mass density (BMD)?

Calcitonin Calcitonin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD. Raloxifene reduces the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. Teriparatide has been recently approved by the FDA for the treatment of osteoporosis. Vitamin D increases the absorption of calcium.

A home care nurse assesses for disease complications in a client with bone cancer. Which laboratory value may indicate the presence of a disease complication?

Calcium level of 11.6 mg/dl In clients with bone cancer, tumor destruction of bone commonly causes excessive calcium release. When the calcium-excreting capacity of the kidneys and GI tract is exceeded, the serum calcium level rises above normal, leading to hypercalcemia (a serum calcium level greater than 10.2 mg/dl). Hyperkalemia (a potassium level greater than 5 mEq/L) isn't caused by bone cancer and is seldom associated with chemotherapy. Hyponatremia (a sodium level less than 135 mEq/L) and hypomagnesemia (a magnesium level less than 1.3 mg/dl) are potential adverse effects of chemotherapy; these electrolyte disturbances don't result directly from bone cancer.

When an infection is bloodborne, the manifestations include which symptom?

Chills Manifestations of bloodborne infection include chills, high fever, rapid pulse, and generalized malaise.

The nurse is planning an education program for women of childbearing years. The nurse recognizes that primary prevention of osteoporosis includes:

Ensuring adequate calcium and vitamin D intake Nutritional intake of calcium and vitamin D are essential for the prevention of osteoporosis.

A provider prescribes a subcutaneous anabolic agent for an elderly patient to prevent fractures associated with osteoporosis. Which of the following is the most likely prescribed drug?

Forteo Teriparatide (Forteo) is a subcutaneously administered anabolic agent that is taken once daily. The other drug choices are oral preparations.

The provider asks a nurse to test a patient for Tinel's sign to diagnose carpal tunnel syndrome. The nurse asked the patient to:

Hold his palm up while the nurse percussed over the median nerve. If tingling, numbness, or pain is felt when the median nerve is percussed, then Tinel's sign is considered positive. Refer to Figure 41-3 in the text.

A nurse notices a client lying on the floor at the bottom of the stairs. He's alert and oriented and states that he fell down several stairs. He denies pain other than in his arm, which is swollen and appears deformed. After calling for help, what should the nurse do?

Immobilize the client's arm. Signs of a fracture in an extremity include pain, deformity, swelling, discoloration, and loss of function. When a nurse suspects a fracture, she should immobilize the extremity before moving the body part. It isn't appropriate for the nurse to move the client into a sitting position without further assessment. The client shouldn't walk to the nurses' station; he should stay where he is until help arrives.

A patient visits an orthopedic specialist because of pain that he feels beginning in his low back and radiating behind his right thigh and down below his right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between these intervertebral disks:

L4, L5, and S1 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.

Which assessment findings would the nurse expect in a client diagnosed with osteomyelitis?

Leukocytosis and localized bone pain Clinical manifestations of osteomyelitis include signs and symptoms of sepsis and localized infection.

A family member is caring for an older adult client with osteomalacia in the home. When the home health nurse comes to evaluate the client, what should be a focus point of the visit?

Observing for safety hazards that could be a fall risk Clients with osteomalacia exhibit a waddling type of gait, putting them at risk for falls and fractures. Safety would be the priority in this circumstance such as scatter rugs, loose boards, and stairs. Older adult clients do not require a daily bath, and it may dry the skin. Nutrition is a necessity to question but the priority would be safety. Whether the client has adequate financial resources would be referred to social service.

The nurse is caring for a client following foot surgery. Which nursing intervention is most important for the nurse to include in the nursing care plan?

Perform neuromuscular assessment every hour. The priority nursing intervention is to perform a neuromuscular assessment every hour. Early detection of neurological and perfusion problems is critical.

The hospice nurse is assigned to care for a patient with metastatic bone cancer who wants to remain at home. What is the therapeutic goal in the care of this patient?

Relieve pain and discomfort while promoting quality of life. The treatment of advanced metastatic bone cancer is palliative. The therapeutic goal is to relieve the patient's pain and discomfort while promoting quality of life.

A client has Paget's disease. An appropriate nursing diagnosis for this client is:

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

Which of the following is the most important nursing diagnosis for an elderly patient diagnosed with osteoporosis?

Risk for injury related to fractures due to osteoporosis The most important concern for an elderly patient with osteoporosis is prevention of falls and fractures. Pain and constipation can be managed, and knowledge can be reinforced, but fractures can cause significant morbidity and mortality.

Most cases of osteomyelitis are caused by which microorganism?

Staphylococcus aureus Staphylococcus aureus causes 70% to 80% of bone infections. While Proteus species, Pseudomonas species, and E. coli are frequently found in osteomyelitis, they do not cause the majority of bone infections.

In chronic osteomyelitis, antibiotics are adjunctive therapy in which situation?

Surgical debridement In chronic osteomyelitis, antibiotics are adjunctive therapy to surgical debridement.

A client has been treated for migraine headaches for several months and comes to the clinic stating he is getting no better. The nurse is talking with the client and hears an audible click when the client is moving his jaw. What does the nurse suspect may be happening?

Temporomandibular disorder The disorder can be confused with trigeminal neuralgia and migraine headaches. The client experiences clicking of the jaw when moving the joint, or the jaw can lock, which interferes with opening the mouth. Loose teeth will not cause a clicking of the jaw. The client does not have a dislocated jaw.

A nurse is caring for a client who's experiencing septic arthritis. This client has a history of immunosuppressive therapy and his immune system is currently depressed. Which assignment is the most appropriate for the nurse caring for this client?

The nurse is caring for this client on the intensive care unit. This client is critically ill; his diagnosis and immunosuppression place him at a high risk for infection. The most appropriate place for this client is in an intensive care unit, where the nurse can focus exclusively on his health promotion. This client shouldn't be on the oncology floor. This client requires close monitoring. The nurse caring for this client shouldn't also be caring for other clients who may require frequent interventions.

Which sign may be helpful in identifying carpal tunnel syndrome?

Tinel's Tinel's sign may be used to help identify carpal tunnel syndrome. The presence of the Babinski's sign can identify disease of the brain and spinal cord in adults and also exists as a primitive reflex in infants. The Brudzinski's and Kernig's sign are indicative of meningeal irritation.

A client with low back pain is being seen in the clinic. In planning care, which teaching point should the nurse include?

Use the large muscles of the leg when lifting items. The large muscles of the leg should be used when lifting.

The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action?

Walk or perform weight-bearing exercises Risk-lowering strategies for osteoporosis include walking or exercising outdoors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, quitting smoking, and consuming alcohol and caffeine in moderation.

To help minimize calcium loss from a hospitalized client's bones, the nurse should:

encourage the client to walk in the hall. Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. Providing dairy products and supplemental feedings wouldn't lessen calcium loss — even if the dairy products and feedings contained extra calcium — because the additional calcium doesn't increase bone stimulation or osteoblast activity.

Which should be included in the teaching plan for a client diagnosed with plantar fasciitis?

Management of plantar fasciitis includes stretching exercises. Management also includes wearing shoes with support and cushioning to relieve pain, orthotic devices (e.g., heel cups, arch supports), and the use of nonsteroidal anti-inflammatory drugs. Plantar fasciitis, an inflammation of the foot-supporting fascia, presents as acute-onset heel pain experienced upon taking the first steps in the morning. The pain is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon. Unresolved plantar fasciitis may progress to fascial tears at the heel and eventual development of heel spurs.

A patient had hand surgery to correct a Dupuytren's contracture. What nursing intervention is a priority postoperatively?

Performing hourly neurovascular assessments for the first 24 hours Hourly neurovascular assessment of the exposed fingers for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion.

A patient diagnosed with carpal tunnel syndrome (CTS) asks the nurse about numbness in the fingers and pain in the wrist. In responding to the patient, how would the nurse best describe CTS?

"CTS is a neuropathy that is characterized by compression of the median nerve at the wrist." Carpal tunnel syndrome is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema, or a soft tissue mass.

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?

Quadriceps 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).