Ch. 41 - Nursing Management: Musculoskeletal Disorders

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.

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 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 for osteoporosis. Estrogen deficiency is linked to decreased bone mass.

A nurse is educating a client diagnosed with osteomalacia. Which statement by the nurse is appropriate?

"You may need to be evaluated for an underlying cause, such as renal failure." Explanation: The client may need to be evaluated for an underlying cause. If an underlying cause is discovered, that will guide the medical treatment. The client needs to maintain an adequate to increased supply of calcium, phosphorus, and vitamin D. Dairy products are a good source of calcium. The client is at risk for pathological fractures and therefore should not engage in vigorous exercise.

A 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. Continuous passive range of motion is used for clients with osteoarthritis. Weight-bearing exercises are used with clients who have osteoporosis. Limiting protein and calcium is not part of the plan of care for clients with osteomyelitis.

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.

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. Teriparatide is an anabolic agent, and denosumab is a monoclonal antibody agent.

A client is scheduled for surgery to fuse a joint. The nurse identifies this as which of the following?

Arthrodesis An arthrodesis is a surgical procedure to fuse a joint. An osteotomy involves cutting and removing a wedge of the bone to change alignment. An arthroplasty is a total reconstruction or replacement of a joint with an artificial joint. Open reduction internal fixation is accomplished with wire, nails, plate and/or an intramedullary rod to hold bone fragments in place until healing is complete.

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.

A client with diabetes punctured the foot with a sharp object. 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?

At least 4 weeks Explanation: Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for at least 4 weeks, followed by another 2 weeks (or more) of IV antibiotics or oral antibiotics.

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.

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

Calcitonin Explanation: 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.

The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response?

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

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

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.

Which of the following was formerly called a bunion?

Hallux valgus Explanation: 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.

A healthcare provider asks a nurse to test a client for Tinel's sign to diagnose carpal tunnel syndrome. What should the nurse do to perform this assessment?

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

A patient with a primary diagnosis of colorectal cancer has developed bone metastases in recent weeks. When reviewing this patient's daily blood work, the nurse should be aware that secondary bone tumors create a significant risk of what electrolyte imbalance?

Hypercalcemia Hypercalcemia is a dangerous complication of bone cancer that is caused by the destruction of bone tissue. Imbalances in potassium, sodium, and chloride are less likely to be attributable to a bone tumor.

Following diagnostic testing, a 69-year-old male patient has been diagnosed with Paget's disease. When planning the subsequent care that this patient is likely to require, what nursing diagnosis should most likely be prioritized by the nurse?

Impaired physical mobility related to Paget's disease In individuals with Paget's disease, the femurs and tibiae tend to bow, producing a waddling gait. The spine is bent forward and is rigid; the chin rests on the chest. These musculoskeletal effects compromise mobility. Peripheral neurovascular dysfunction is less common than these characteristic skeletal changes. Impaired skin integrity and unilateral neglect are not commonly associated with Paget's disease.

Assessment of a client reveals signs and symptoms of Paget's disease. Which of the following would be most likely?

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

The community health nurse is assessing the risk factors for osteoporosis in a female client at a health fair.

Risk Factors for Osteoporosis - 66 years of age - asian heritage - postmenopasual status - takes fluticasone inhaler for asthma NOT a Risk Factor for Osteoporosis - large frame - nonsmoker - alcohol intake of 3 drinks/week - walks.2 miles, 3 days/week

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

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

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

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

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

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

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing?

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.

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 client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the 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.

After several weeks of antibiotic therapy for the treatment of osteomyelitis, a patient is preparing for discharge. When providing health education related to self-care, the nurse should emphasize which of the following topics?

The importance of adhering to further antibiotic treatment After initial treatment for osteomyelitis, the patient and family are taught about the importance of strictly adhering to the therapeutic regimen of antibiotics. This supersedes the importance of nutrition, even though this is important. There is no specific need to avoid ASA, and activity may be limited to reduce the risk of injury.

A nurse is teaching a 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.

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.

What clinical manifestation 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.

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.

Which group is at the greatest risk for osteoporosis?

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

During a routine physical examination of a client, the nurse observes a flexion deformity of the proximal interphalangeal (PIP) joint of two toes on the right foot. How would the nurse document this finding?

Hammer toe Explanation: 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.

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.

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).

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

The nurse is caring for a patient with a bone tumor. The nurse provides education that teaches the patient to implement measures to reduce the risk of pathologic fractures. What intervention will assist the patient in fracture prevention?

Supporting the affected extremity with external supports (splints) Explanation: During nursing care, the affected extremities must be supported and handled gently. External supports (splints) may be used for additional protection. Prolonged bed rest is not therapeutic and leads to loss of function and muscle atrophy. Assistive devices should be used to strengthen the unaffected extremities. Weight-bearing must be undertaken cautiously.

A nurse is caring for a client who's experiencing septic arthritis. This client has a history of immunosuppressive therapy and the 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; the diagnosis and immunosuppression place the client 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 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.

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

Walk or perform weight-bearing exercises Explanation: 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.

A nurse is planning discharge teaching regarding exercise for a client at risk for osteoporosis. Which exercise would the nurse be most likely to suggest?

Walking Explanation: Weight-bearing exercises should be incorporated into the client's lifestyle activities. Walking is a low-impact method of weight-bearing exercise and would be the most universal or most likely form of exercise for the nurse to recommend. Bicycling, and swimming are not weight-bearing exercise and will not increase bone density. Yoga may or may not be weight-bearing exercise depending on the yoga poses being performed; it is not as likely as walking to be recommended by the nurse.

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 nurse practitioner who works with many older adult patients integrates screening for osteoporosis into health promotion activities. What screening tool is most clinically useful when screening for osteoporosis?

Hip bone mineral density (BMD) testing Current evidence-based guidelines recommend the use of hip BMD as the first-line screening test for osteoporosis. This is a clearer indicator of osteoporosis risk than is assessment of calcium levels. Bone biopsy and direct analysis of vitamin D levels are not used as screening methods.

The nurse is discussing conservative management of tendonitis with a patient. Which of the following is likely the most effective approach to managing tendonitis?

Intermittent application of ice and heat Explanation: Conservative management of tendonitis includes rest of the extremity, intermittent ice and heat to the joint, and nonsteroidal anti-inflammatory drugs to control the inflammation and pain. Weight reduction, stress reduction, and ROM exercises are not part of conservative management of tendonitis.

A 67-year-old woman with a history of osteoarthritis has been admitted to the postsurgical unit from the PACU following a bunionectomy. Which of the following nursing actions should the nurse integrate into this patient's immediate care?

Keep the patient's foot elevated above the level of her heart. Post bunionectomy, the patient may have intense throbbing pain at the operative site, requiring liberal doses of analgesic medication. The foot is elevated to the level of the heart to decrease edema and pain. The application of ice for a 1-hour period is likely to cause skin breakdown. It is unnecessary to perform frequent irrigation or dressing changes.

A client with carpal tunnel syndrome has had limited improvement with the use of a wrist splint. The nurse knows that which procedure will show the greatest improvement in treatment for this client?

Open nerve release Evidence-based treatment of acute carpal tunnel syndrome includes the application of splints to prevent hyperextension and prolonged flexion of the wrist. Should this treatment fail, open nerve release is a common surgical management option. A variety of treatments may be tried by the client, however, they may fail to improve the condition. These treatments include laser therapy, ultrasound therapy, and the injection of substances such as lidocaine. Though these can be used, surgery to release nerves is the best option.

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. Explanation: 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 collaborating with the health care provider on a plan of care for a 54-year-old male client with osteomyelitis of the left femur secondary to uncontrolled type 1 diabetes. Click to highlight the prescriptions for care that the nurse should anticipate for this client.

*Perform neurovascular checks of lower extremities every 8 hours. *Administer IV antibiotic based on culture and sensitivity report. *Encourage ambulation with weight-bearing on the left leg. *Administer ibuprofen 400 mg orally three times daily, as needed for pain. *Make referral to dietitian to discuss nutrition for healing and blood glucose control. *Provide education on self-blood glucose monitoring and insulin administration. Osteomyelitis is a bone infection that produces pain, inflammation, swelling, and impaired mobility and requires prompt treatment to treat the infection and prevent loss of limb. The nurse should perform neurovascular checks of the affected leg every 8 hours to detect the development of nerve or vascular impairment. Osteomyelitis is treated with IV antibiotics determined by the identified pathogen on culture and sensitivity testing. Because there is reduced penetration of antibiotics in the bone tissue, IV antibiotic therapy may be needed for 6 to 12 weeks, followed by oral antibiotics. The pain of osteomyelitis can be controlled with oral analgesics, such as ibuprofen.The client should consume a healthy diet to promote bone healing and control blood glucose levels. Because uncontrolled blood glucose levels increase the risk for osteomyelitis and impair bone healing, the nurse should educate the client about self-blood glucose monitoring and insulin administration. The client's affected left leg should be elevated to reduce swelling and pain. The affected leg should not be placed in the dependent position. Because the bone is weakened by the infectious process, the client should avoid placing stress on the bone through weight-bearing activity.

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.