Ch 63: Musculoskeletal Problems

A patient with osteomyelitis is to receive vancomycin (Vancocin) 500 mg IV every 6 hours. The vancomycin is diluted in 100 mL of normal saline and needs to be administered over 1 hour. The nurse will set the IV pump for how many mL/minute?

1.67. To administer 100 mL in 60 minutes, the IV pump will need to provide 1.67 mL/minute.

In which order will the nurse implement these collaborative interventions prescribed for a patient being admitted who has 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. Send to radiology for computed tomography (CT) scan of right leg. c. Administer gentamicin (Garamycin) 60 mg IV. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever.

A, C, D, B. The highest 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.

Which actions will the nurse include in the plan of care when caring for a patient with metastatic bone cancer of the left femur (select all that apply)? a. Monitor serum calcium level. b. Teach about the need for strict bed rest. c. Avoid use of sustained-release opioids for pain. d. Support the left leg when repositioning the patient. e. Support family as they discuss the prognosis of patient

A, D, E. The nurse will monitor for hypercalcemia caused by bone decalcification. Support of the leg helps reduce the risk for pathologic fractures. Although the patient may be reluctant to exercise, activity is important to maintain function and avoid the complications associated with immobility. Adequate pain medication, including sustained-release and rapidly acting opioids, is needed for the severe pain that is frequently associated with bone cancer. The prognosis for metastatic bone cancer is poor so the patient and family need to be supported as they deal with the reality of the situation.

The nurse evaluating effectiveness of prescribed calcitonin (Cibacalcin) and ibandronate (Boniva) for a patient with Paget's disease will consider the patient's a. pain level. b. oral intake. c. daily weight. d. grip strength.

A. Bone pain is one of the common early manifestations of Paget's disease, and the nurse should assess the pain level to determine whether the treatment is effective. The other information will also be collected by the nurse, but will not be used in evaluating the effectiveness of the therapy.

A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will be included in the initial plan of care? a. Immobilization of the left leg b. Positioning the left leg in flexion c. Assisted weight-bearing ambulation d. Quadriceps-setting exercise repetitions

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

Which action will the nurse take when caring for a patient with osteomalacia? a. Teach about the use of vitamin D supplements. b. Educate about the need for weight-bearing exercise. c. Discuss the use of medications such as bisphosphonates. d. Emphasize the importance of sunscreen use when outside.

A. Osteomalacia is caused by inadequate intake or absorption of vitamin D. Weight-bearing exercise and bisphosphonate administration may be used for osteoporosis but will not be beneficial for osteomalacia. Because ultraviolet light is needed for the body to synthesize vitamin D, the patient might be taught that 20 minutes/day of sun exposure is beneficial.

An assessment finding for a 55-year-old patient that alerts the nurse to the presence of osteoporosis is a. a measurable loss of height. b. the presence of bowed legs. c. the aversion to dairy products. d. a statement about frequent falls.

A. Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate that osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis.

A 23-year-old patient with a history of muscular dystrophy is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Logroll the patient every 2 hours. b. Assist the patient with ambulation. c. Discuss the need for genetic testing with the patient. d. Teach the patient about the muscle biopsy procedure.

B. Because the goal for the patient with muscular dystrophy is to keep the patient active for as long as possible, assisting the patient to ambulate will be part of the care plan. The patient will not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but are not necessary for a patient who already has a diagnosis. There is no need for genetic testing because the patient already knows the diagnosis.

A 39-year-old patient whose work involves frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates that the teaching has been effective? a. "I will keep my back straight to lift anything higher than my waist." b. "I will begin doing exercises to strengthen the muscles of my back." c. "I can try to sleep with my hips and knees extended to prevent back strain." d. "I can tell my boss that I need to change to a job where I can work at a desk."

B. Exercises can help strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back. Modifications in the way the patient lifts boxes are needed, but sitting for prolonged periods can aggravate back pain. The patient should not lift above the level of the elbows.

Which action should the nurse take before administering gentamicin (Garamycin) to a patient who has acute osteomyelitis? a. Ask the patient about any nausea. b. Review the patient's creatinine level. c. Obtain the patient's oral temperature. d. Change the prescribed wet-to-dry dressing.

B. Gentamicin is nephrotoxic and can cause renal failure. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.

The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which statement by a patient indicates that additional patient teaching is needed? a. "I will need to participate in physical therapy after surgery." b. "I did not have this bone cancer until my leg broke a week ago." c. "I wish that I did not have to have chemotherapy after this surgery." d. "I can use the patient-controlled analgesia (PCA) to control postoperative pain."

B. Osteogenic sarcoma may be diagnosed following a fracture, but it is not caused by the injury. The other patient statements indicate that patient teaching has been effective.

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. c. Suggest that the patient alternate the use of heat and cold to the neck to treat the pain. d. Teach about the use of nonsteroidal antiinflammatory drugs such as ibuprofen (Advil).

B. The nurse's initial action should be further assessment of the pain because cervical nerve root compression will require different treatment than musculoskeletal neck pain. The other actions may also be appropriate, depending on the assessment findings.

A 50-year-old patient is being discharged after a 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 the long-term IV catheter c. The need for daily aerobic exercise to help maintain muscle strength d. The reason for taking oral antibiotics for 7 to 10 days after discharge

B. The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and 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.

Following laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action that the nurse should take is to a. report the patient's complaint to the surgeon. b. check the chart for preoperative assessment data. c. check the vital signs for indications of hemorrhage. d. turn the patient to the side to relieve pressure on the right leg.

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. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness.

When administering alendronate (Fosamax) to a patient with osteoporosis, the nurse will a. ask about any leg cramps or hot flashes. b. assist the patient to sit up at the bedside. c. be sure that the patient has recently eaten. d. administer the ordered calcium carbonate.

B. To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates.

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. Avoid activities that require twisting of the back or prolonged sitting. d. Symptoms of acute low back pain frequently improve in a few weeks. e. Ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) can be used 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 who works on the orthopedic unit has just received the change-of-shift report. Which patient should the nurse assess first? a. Patient who reports foot pain after hammertoe surgery b. Patient with low back pain and a positive straight-leg-raise test c. Patient who has not voided 10 hours after having a laminectomy d. Patient with osteomyelitis who has a temperature of 100.5° F (38.1° C)

C. Difficulty in voiding may indicate damage to the spinal nerves and should be assessed and reported to the surgeon immediately. The information about the other patients is consistent with their diagnoses. The nurse will need to assess them as quickly as possible, but the information about them does not indicate a need for immediate intervention.

A 67-year-old patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse chooses a nursing diagnosis of ineffective health maintenance when the nurse finds that the patient a. is frustrated with the length of treatment required. b. takes and records the oral temperature twice a day. c. is unable to plantar flex the foot on the affected side. d. uses crutches to avoid weight bearing on the affected leg.

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 nursing action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Check ability to plantar and dorsiflex the foot. b. Determine the patient's readiness to ambulate. c. Log roll the patient from side to side every 2 hours. d. Ask about pain control with the patient-controlled analgesia (PCA).

C. Repositioning a patient is included in the education and scope of practice of UAP, and experienced UAP will be familiar with how to maintain alignment in the postoperative patient. Evaluation of the effectiveness of pain medications, assessment of neurologic function, and evaluation of a patient's readiness to ambulate after surgery require higher level nursing education and scope of practice.

An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to a. keep both feet flat on the floor when prolonged standing is required. b. twist gently from side to side to maintain range of motion in the spine. c. keep the head elevated slightly and flex the knees when resting in bed. d. avoid the use of cold packs because they will exacerbate the muscle spasms.

C. Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. A pillow placed under the upper back will cause strain on the lumbar spine. Alternate application of cold and heat should be used to decrease pain.

The nurse should reposition the patient who has just had a laminectomy and diskectomy by a. instructing the patient to move the legs before turning the rest of the body. b. having the patient turn by grasping the side rails and pulling the shoulders over. c. placing a pillow between the patient's legs and turning the entire body as a unit. d. turning the patient's head and shoulders first, followed by the hips, legs, and feet.

C. The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.

Which assessment finding for a patient who has had a surgical reduction of an open fracture of the right radius is most important to report to the health care provider? a. Serous wound drainage b. Right arm muscle spasms c. Right arm pain with movement d. Temperature 101.4° F (38.6° C)

D. An elevated temperature is suggestive of possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.

A 54-year-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman about her osteoporosis, the nurse explains that a. estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. b. continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. c. with a family history of osteoporosis, there is no way to prevent or slow gradual bone resorption. d. calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.

D. Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy does help prevent osteoporosis, but it is not the only treatment and is not appropriate for some patients. Corticosteroid therapy increases the risk for osteoporosis.

Which menu choice by a patient with osteoporosis indicates that the nurse's teaching about appropriate diet has been effective? a. Pancakes with syrup and bacon b. Whole wheat toast and fresh fruit c. Egg-white omelet and a half grapefruit d. Oatmeal with skim milk and fruit yogurt

D. Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods.

The nurse will determine that more teaching is needed if a patient with discomfort from a bunion says, "I will a. give away my high-heeled shoes." b. take ibuprofen (Motrin) if I need it." c. use the bunion pad to cushion the area." d. only wear sandals, no closed-toe shoes."

D. The patient can wear shoes that have a wide forefoot. The other patient statements indicate that the teaching has been effective.