Chapter 42

Which of the following patients should the nurse recognize as being at the highest risk for the development of osteomyelitis?

Ans: An elderly patient with an infected pressure ulcer in the sacral area Feedback: Patients who are at high risk of osteomyelitis include those who are poorly nourished, elderly, and obese. The elderly patient with an infected sacral pressure ulcer is at the greatest risk for the development of osteomyelitis, as this patient has two risk factors: age and the presence of a soft-tissue infection that has the potential to extend into the bone. The patient with rheumatoid arthritis has one risk factor and the infant with jaundice has no identifiable risk factors. The patient 6 weeks postsurgery is beyond the usual window of time for the development of a postoperative surgical wound infection.

A nurse is caring for a patient with Paget's disease and is reviewing the patient's most recent laboratory values. Which of the following values is most characteristic of Paget's disease?

Ans: An elevated serum alkaline phosphatase level and a normal serum calcium level Feedback: Patients with Paget's disease have normal blood calcium levels. Elevated serum alkaline phosphatase concentration and urinary hydroxyproline excretion reflect the increased osteoblastic activity associated with this condition. Alterations in PTH and calcitonin levels are atypical.

A nurse is caring for an adult patient diagnosed with a back strain. What health education should the nurse provide to this patient?

Ans: Avoid lifting more than one-third of body weight without assistance. Feedback: The nurse will instruct the patient on the safe and correct way to lift objects—using the strong quadriceps muscles of the thighs, with minimal use of the weak back muscles. To prevent recurrence of acute low back pain, the nurse may instruct the patient to avoid lifting more than one-third of his weight without help. The patient should be informed to place the feet a hip-width apart to provide a wide base of support, the person should bend the knees, tighten the abdominal muscles, and lift the object close to the body with a smooth motion, avoiding twisting and jerking.

An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis?

Ans: Bone fracture Feedback: Bone fracture is a major complication of osteoporosis that 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 is not a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

A nurse is reviewing the pathophysiology that may underlie a patient's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation?

Ans: Calcitonin Feedback: Calcitonin inhibits bone resorption and promotes bone formation, estrogen inhibits bone breakdown, and parathyroid increases bone resorption. Estrogen, which inhibits bone breakdown, decreases with aging. Parathyroid hormone (PTH) increases with aging, increasing bone turnover and resorption. Progesterone is the major naturally occurring human progestogen and plays a role in the female menstrual cycle.

A patient has been admitted to the medical unit for the treatment of Paget's disease. When reviewing the medication administration record, the nurse should anticipate what medications? Select all that apply.

Ans: Calcitonin, Bisphosphonates Feedback: Bisphosphonates are the cornerstone of Paget therapy in that they stabilize the rapid bone turnover. Calcitonin is also used because it retards bone resorption by decreasing the number and availability of osteoclasts. Alkaline phosphatase is a naturally occurring enzyme, not a drug. Calcium gluconate and estrogen are not used in the treatment of Paget's disease.

A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended adequate intake of what nutrients? Select all that apply.

Ans: Calcium, Vitamin D Feedback: A diet rich in calcium and vitamin D protects against skeletal demineralization. Intake of vitamin B12and potassium does not directly influence the risk for osteoporosis. Calcitonin is not considered to be a dietary nutrient.

A patient tells the nurse that he has pain and numbness to his thumb, first finger, and second finger of the right hand. The nurse discovers that the patient is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the patient could possibly have what health problem?

Ans: Carpel tunnel syndrome Feedback: Carpel tunnel syndrome may be manifested by numbness, pain, paresthesia, and weakness along the median nerve. Tendonitis is inflammation of muscle tendons. Impingement syndrome is a general term that describes all lesions that involve the rotator cuff of the shoulder. Dupuytren's contracture is a slowly progressive contracture of the palmar fascia.

A nurse is teaching a patient with osteomalacia about the role of diet. What would be the best choice for breakfast for a patient with osteomalacia?

Ans: Cereal with milk, a scrambled egg, and grapefruit Feedback: The best meal option is the one that contains the highest dietary sources of calcium and vitamin D. The best selection among those listed is cereal with milk, and eggs, as these foods contain calcium and vitamin D in a higher quantity over the other menu options.

A nurse is caring for a patient who is being assessed following complaints of severe and persistent low back pain. The patient is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? that apply.

Ans: Computed tomography (CT), Magnetic resonance imaging (MRI), Ultrasound, X-ray Feedback: A variety of diagnostic tests can be used to address lower back pain, including CT, MRI, ultrasound, and X-rays. Angiography is not related to the etiology of back pain.

A patient has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. Which of the following nursing diagnoses must be addressed in the plan of care?

Ans: Constipation Related to Vertebral Fracture Feedback: Constipation is a problem related to immobility and medications used to treat vertebral fractures. The patient's risks of aspiration, dysphagia, and decreased cardiac output are not necessarily heightened.

A nurse is reviewing the care of a patient who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug?

Ans: Cyclobenzaprine Feedback: Short-term prescription muscle relaxants (e.g., cyclobenzaprine [Flexeril]) are effective in relieving acute low back pain. ASA is not normally used for pain control, due to its antiplatelet action and associated risk for bleeding. Calcitonin and corticosteroids are not used in the treatment of lower back pain.

A patient has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery?

Ans: Delayed wound healing Feedback: Delayed wound healing is a complication of surgery due to tissue trauma from the surgery. Nutritional deficiency is usually due to the effects of chemotherapy and radiation therapy, which may cause weight loss. Pathologic fractures are not a complication of surgery.

A patient's electronic health record notes that the patient has hallux valgus. What signs and symptoms would the nurse expect this patient to manifest?

Ans: Deviation of a great toe laterally Feedback: A deformity in which the great toe deviates laterally and there is a marked prominence of the medial aspect of the first metatarsal-phalangeal joint and exostosis is referred to as hallux valgus (bunion). Hallux valgus does not result in abnormal flexion, abnormalities of the arch, or joint fusion.

A patient presents at the clinic with complaints of morning numbness, cramping, and stiffness in his fourth and fifth fingers. What disease process should the nurse suspect?

Ans: Dupuytren's disease Feedback: In cases of Dupuytren's disease, the patient may experience dull, aching discomfort, morning numbness, cramping, and stiffness in the affected fingers. This condition starts in one hand, but eventually both hands are affected. This clinical scenario does not describe tendonitis, a ganglion, or carpal tunnel syndrome.

A nurse is caring for a patient who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure will the nurse implement to control the edema?

Ans: Elevate the foot on several pillows. Feedback: To control the edema in the foot of a patient who experienced foot surgery, the nurse will elevate the foot on several pillows when the patient is sitting or lying. Diuretic therapy is not an appropriate intervention for edema related to inflammation. Intermittent ice packs should be applied to the surgical area during the first 24 to 48 hours after surgery to control edema and provide some pain relief. Ambulation will gradually be resumed based on the guidelines provided by the surgeon.

A nurse is planning the care of an older adult patient with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis?

Ans: Ensuring adequate exposure to sunlight Feedback: Because sunlight is necessary for synthesizing vitamin D, patients should be encouraged to spend some time in the sun. A low-purine diet is not a relevant action and thyroid supplements do not directly affect bone function. Action must be taken to prevent fractures, but weight-bearing exercise within safe parameters is not necessarily contraindicated.

A patient presents at a clinic complaining of pain in his heel so bad that it inhibits his ability to walk. The patient is subsequently diagnosed with plantar fasciitis. This patient's plan of care should include what intervention?

Ans: Gently stretching the foot and the Achilles tendon Feedback: Plantar fasciitis leads to pain that is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon. Dressings of any kind are not of therapeutic benefit and analgesic ointments do not address the pathology of the problem. Open-toed shoes are of no particular benefit.

A nurse is providing care for a patient who has a recent diagnosis of Paget's disease. When planning this patient's nursing care, interventions should address what nursing diagnoses? Select all that apply.

Ans: Impaired Physical Mobility, Acute Pain, Disturbed Auditory Sensory Perception, Risk for Injury Feedback: Patient's with Paget's disease are at risk of decreased mobility, pain, hearing loss, and injuries resulting from decreased bone density. Paget's disease does not affect blood glucose levels.

An older adult woman's current medication regimen includes alendronate (Fosamax). What outcome would indicate successful therapy?

Ans: Increased bone mass Feedback: Bisphosphonates such as Fosamax increase bone mass and decrease bone loss by inhibiting osteoclast function. These drugs do not treat infection, pain, or tumors.

A nurse is caring for a patient who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention?

Ans: Intermittent application of heat to the patient's back Feedback: Intermittent local heat and back rubs promote muscle relaxation following osteoporotic vertebral fractures. High Fowler's positioning is likely to exacerbate pain. The mattress must be adequately supportive, but pressure reduction is not necessarily required. Passive range of motion exercises to the back would cause pain and impair healing.

A nurse is discussing conservative management of tendonitis with a patient. Which of the following may be an effective approach to managing tendonitis?

Ans: Intermittent application of ice and heat Feedback: Conservative management of tendonitis includes rest of the extremity, intermittent ice and heat to the joint, and NSAIDs. Weight reduction may prevent future injuries but will not relieve existing tendonitis. Range-of-motion exercises may exacerbate pain. Opioids would not be considered a conservative treatment measure.

An older adult patient sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize which of the following aspects of care?

Ans: Intravenous administration of antibiotics Feedback: IV antibiotics are the major treatment modality for septic arthritis; the nurse must ensure timely administration of these drugs. Corticosteroids are not used to treat septic arthritis and vitamin D levels are not necessarily affected. Falls prevention is important, but septic arthritis does not constitute the same fracture risk as diseases with decreased bone density.

A patient is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results is most suggestive of this diagnosis?

Ans: Low serum calcium and low phosphorus level Feedback: Laboratory studies will reveal a low serum calcium and low phosphorus level.

A nurse is providing care for a patient who has osteomalacia. What major goal will guide the choice of medical and nursing interventions?

Ans: Maintenance of adequate levels of activated vitamin D Feedback: The primary defect in osteomalacia is a deficiency of activated vitamin D, which promotes calcium absorption from the gastrointestinal tract and facilitates mineralization of bone. Interventions are aimed at resolving the processes underlying this deficiency. Maintenance of skin integrity is important, but is not the primary goal in care. Osteomalacia is not a malignant process. Overproduction (not underproduction) of PTH can cause the disease.

A nurse is assessing a patient who reports a throbbing, burning sensation in the right foot. The patient states that the pain is worst during the day but notes that the pain is relieved with rest. The nurse should recognize the signs and symptoms of what health problem?

Ans: Morton's neuroma Feedback: Morton's neuroma is a swelling of the third (lateral) branch of the median plantar nerve, which causes a throbbing, burning pain, usually relieved with rest. Pescavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Hallux valgus (bunion) is a deformity in which the great toe deviates laterally and there is a marked prominence of the medial aspect of the first metatarsal-phalangeal joint and exostosis. Onychocryptosis (ingrown toenail) occurs when the free edge of a nail plate penetrates the surrounding skin, laterally or anteriorly.

A patient has come to the clinic for a routine annual physical. The nurse practitioner notes a palpable, painless projection of bone at the patient's shoulder. The projection appears to be at the distal end of the humerus. The nurse should suspect the presence of which of the following?

Ans: Osteochondroma Feedback: Osteochondroma is the most common benign bone tumor. It usually occurs as a large projection of bone at the end of long bones (at the knee or shoulder). Osteomyelitis, osteomalacia, and Paget's disease do not involve the development of excess bone tissue.

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The patient should undergo diagnostic testing for what health problem?

Ans: Osteomyelitis Feedback: When osteomyelitis develops from the spread of an adjacent infection, no signs of septicemia are present, but the area becomes swollen, warm, painful, and tender to touch. Osteoporosis is the most prevalent bone disease in the world. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Septicarthritis occurs when joints become infected through spread of infection from other parts of the body (hematogenous spread) or directly through trauma or surgical instrumentation.

A patient with diabetes has been diagnosed with osteomyelitis. The nurse notes that the patient's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis?

Ans: Osteomyelitis with vascular insufficiency Feedback: Osteomyelitis is classified as hematogenous osteomyelitis (i.e., due to blood-borne spread of infection); contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury (e.g., gunshot wound); and osteomyelitis with vascular insufficiency, seen most commonly among patients with diabetes and peripheral vascular disease, most commonly affecting the feet. Osteomyelitis with muscular deterioration does not exist.

A nurse is providing discharge teaching for a patient who underwent foot surgery. The nurse is collaborating with the occupational therapist and discussing the use of assistive devices. On what variables does the choice of assistive devices primarily depend?

Ans: Patient's general condition, balance, and weight-bearing prescription Feedback: Assistive devices (e.g., crutches, walker) may be needed. The choice of the devices depends on the patient's general condition and balance, and on the weight-bearing prescription. The patient's strength, motivation, and weight restrictions are not what the choice of assistive devices is based on.

A patient with diabetes is attending a class on the prevention of associated diseases. What action should the patient perform to reduce the risk of osteomyelitis?

Ans: Perform meticulous foot care. Feedback: Diabetic foot ulcers have a high potential for progressing to osteomyelitis. Meticulous foot care can help mitigate this risk. Corticosteroids can exacerbate the risk of osteomyelitis. Increased intake of calcium and vitamins as well as regular exercise are beneficial health promotion exercises, but they do not directly reduce the risk of osteomyelitis.

A patient presents at a clinic complaining of back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?

Ans: Sciatica Feedback: Sciatica nerve pain travels down the back of the thigh to the foot of the affected leg. Bursitis is inflammation of a fluid-filled sac in a joint. Radiculopathy is disease of a nerve root. Tendonitis is inflammation of muscle tendons.

A nurse is providing a class on osteoporosis at the local seniors' center. Which of the following statements related to osteoporosis is most accurate?

Ans: Slow discontinuation of corticosteroid therapy can halt the progression of the osteoporosis. Feedback: When corticosteroid therapy is discontinued, the progression of osteoporosis is halted, but restoration of lost bone mass does not occur. Osteoporosis is not a disease of the elderly because its onset occurs earlier in life, when bone mass peaks and then begins to decline. A person's level of physical activity is a modifiable factor that influences peak bone mass. Lack of activity increases the risk for the development of osteoporosis. Primary osteoporosis occurs in women after menopause.

A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What risk factor of the following should the educator describe?

Ans: Small frame, female gender, and Caucasian ethnicity Feedback: Small-framed, nonobese Caucasian women are at greatest risk for osteoporosis. Diabetes, high protein intake, alcohol use, and infections are not among the most salient risk factors for osteoporosis.

A patient presents to a clinic complaining of a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is what?

Ans: Staphylococcus aureus Feedback: S. aureus causes over 50% of bone infections. Proteus, Pseudomonas, and E. coli are also causes, but to a lesser extent.

A nurse is collaborating with the physical therapist to plan the care of a patient with osteomyelitis. What principle should guide the management of activity and mobility in this patient?

Ans: Stress on the weakened bone must be avoided. Feedback: The patient with osteomyelitis has bone that is weakened by the infective process and must be protected by avoidance of stress on the bone.This risk guides the choice of activity in a patient with osteomyelitis. Bed rest is not normally indicated, however. Maintenance of prediagnosis ADLs may be an unrealistic short-term goal for many patients.

The health care team is caring for a patient with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What is the usual treatment for osteomalacia caused by malabsorption?

Ans: Supplemental calcium and increased doses of vitamin D Feedback: If osteomalacia is caused by malabsorption, increased doses of vitamin D, along with supplemental calcium, are usually prescribed.

A 32-year-old patient comes to the clinic complaining of shoulder tenderness, pain, and limited movement. Upon assessment the nurse finds edema. An MRI shows hemorrhage of the rotator cuff tendons and the patient is diagnosed with impingement syndrome. What action should the nurse recommend in order to promote healing?

Ans: Support the affected arm on pillows at night. Feedback: The patient should support the affected arm on pillows while sleeping to keep from turning onto the shoulder. Corticosteroids are not commonly prescribed and a sling is not normally necessary. ROM exercises are indicated, but putting the arm through its full ROM may cause damage during the healing process.

A nurse is caring for a patient with a bone tumor. The nurse is providing education to help the patient reduce the risk for pathologic fractures. What should the nurse teach the patient?

Ans: Support the affected extremity with external supports such as splints. Feedback: During nursing care, the affected extremities must be supported and handled gently. External supports (splints) may be used for additional protection. Prescribed weight-bearing restrictions must be followed. Assistive devices should be used to strengthen the unaffected extremities.

An orthopedic nurse is caring for a patient who is postoperative day one following foot surgery. What nursing intervention should be included in the patient's subsequent care?

Ans: The foot should be elevated in order to prevent edema. Feedback: Pain experienced by patients who undergo foot surgery is related to inflammation and edema. To control the anticipated edema, the foot should be elevated on several pillows when the patient is sitting or lying. Regular dressing changes are performed and the wound should be kept dry. Hydrogen peroxide is not used to cleanse surgical wounds.