Chapter 50 - Musculoskeletal Problems

A client with bone cancer is scheduled for a right upper extremity amputation. Which statement by the client's husband indicates an effective coping strategy?

"I'll have to find ways to help my wife focus on positive aspects of her body." Planning to help the client focus on positive aspects of her body illustrates that the husband is coping with the change in his wife's body image in a positive way

The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.)

Barbiturates Corticosteroids Loop diuretics

The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.)

Draining sinus tracts Presence of foot ulcers

During a community education program the nurse is asked about the risk of a woman breaking a bone due to osteoporosis after age 50. The nurse knows which of the following is the risk?

1 in 2 women Rationale: One in two women over the age of 50 will break a bone because of osteoporosis. A woman's risk of breaking a hip due to osteoporosis is equal to her risk of breast, ovarian, and uterine cancer combined. Women have lighter, thinner bones than men. Many women also lose bone quickly after menopause. Up to one in four men over the age of 50 will break a bone because of osteoporosis. A man older than age 50 is more likely to break a bone due to osteoporosis than he is to get prostate cancer.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.)

Alcohol Caffeine Carbonated beverages Vitamin D Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor.

A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.)

Adherence to the antibiotic regimen Eating high-protein and high-carbohydrate foods Proper use of the intravenous equipment

A client with Paget's disease is hospitalized for an unrelated issue. The client reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Applying a heating pad Providing a massage

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best?

Arrange a home safety evaluation This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation.

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best?

Ask the client about a fear of falling Fear of falling can limit participation in activity. The nurse should first assess if the client has this fear and then offer suggestions for dealing with it.

A client is in the internal medicine clinic reporting bone pain. The client's alkaline phosphatase level is 180 units/L. What action by the nurse is most appropriate?

Assess the client for leg bowing. This client has manifestations of Paget's disease. The nurse should assess for other manifestations such as bowing of the legs.

A client has scoliosis with a 65-degree curve to the spine. What action by the nurse takes priority?

Assess the client's cardiac and respiratory systems. This degree of curvature of the spine affects cardiac and respiratory function. The nurse's priority is to assess those systems.

A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs?

Assess the client's coping skills and support systems. The first step in the nursing process is assessment. The nurse should assess coping skills and possible support systems that will be helpful in this client's treatment.

A client is admitted with a bone tumor. The nurse finds the client weak and lethargic with decreased deep tendon reflexes. What actions by the nurse are best? (Select all that apply.)

Assess the daily serum calcium level. Consult the provider about a loop diuretic. Instruct the client to call for help out of bed.

A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first?

Client taking raloxifene (Evista) who reports unilateral calf swelling The client on raloxifene needs to be seen first because of the manifestations of deep vein thrombosis, which is an adverse effect of raloxifene

The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option?

Client with a spinal cord injury who cannot tolerate sitting up Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The client who cannot tolerate sitting up is not a good candidate for this class of drug.

A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best?

Consult with the provider about an x-ray Back pain with tenderness is indicative of a spinal compression fracture, which is the most common type of osteoporotic fracture. The nurse should consult the provider about an x-ray.

A client is starting on risedronate (Actonel) for treatment of Paget's disease. What precaution does the nurse include in the client's health teaching about this drug?

Drink a full glass of water after taking the drug Risedronate (Actonel), a drug taken orally, should be taken with a full glass of water.

A client is suspected to have muscular dystrophy. About what diagnostic testing does the nurse educate the client? (Select all that apply.)

Electromyography Muscle biopsy Serum aldolase Serum creatinine kinase

A client in a nursing home refuses to take medications. She is at high risk for osteomalacia. What action by the nurse is best?

Ensure the client gets 15 minutes of sun exposure daily. Sunlight is a good source of vitamin D, and the nursing staff can ensure some sun exposure each day

A client is scheduled for a bone biopsy. What action by the nurse takes priority?

Ensuring that informed consent is on the chart The priority is to ensure that informed consent is on the chart. The preoperative medications should not be administered until the nurse is confident the procedure will occur and the client has already signed the consent, if the medications include anxiolytics or sedatives or opioids.

The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the health care provider will request which medication?

Ergocalciferol (Calciferol) Osteomalacia is loss of bone related to vitamin D deficiency. The major treatment for osteomalacia is vitamin D in an active form such as ergocalciferol.

Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need for further teaching by the nurse?

I will cut down to only three martinis at night Clients should eliminate or substantially decrease their alcohol intake to decrease their risk of developing osteoporosis. The client should be taught that three martinis is still considered too much intake of alcohol.

What information does the nurse teach a women's group about osteoporosis?

For 5 years after menopause you lose 2% of bone mass yearly Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.

A client has a metastatic bone tumor. What action by the nurse takes priority?

Handle the affected extremity with caution. Bones invaded by tumors are very fragile and fracture easily. For client safety, the nurse handles the affected extremity with great care.

A hospitalized client is being treated for Ewing's sarcoma. What action by the nurse is most important?

Handling and disposing of chemotherapeutic agents per policy All actions are appropriate for this client. However, for safety, the nurse should place priority on proper handling and disposal of chemotherapeutic agents.

The nurse is assessing a client with osteomalacia. Which findings does the nurse expect to observe? (Select all that apply.)

Hypophosphatemia Looser's lines of zones Unsteady gait Osteomalacia is loss of bone related to vitamin D deficiency, which can lead to bone softening and inadequate deposits of calcium and phosphorus in the bone matrix; this may cause hypophosphatemia. Looser's lines or zones (radiolucent bands) represent stress fractures and are a classic diagnostic finding of osteomalacia

Which nursing intervention helps to reduce the incidence of osteomyelitis for a client receiving hemodialysis?

Instructing the client to brush teeth after every meal Proper dental hygiene helps prevent periodontal infection, which can be a causative factor in osteomyelitis of the facial bone.

An older adult client is discharged from the hospital for treatment of osteoporosis. What does the nurse include in client teaching related to the client's home safety?

Keep walkways free of clutter. Walkways in the home must be clear of clutter and obstacles to help prevent falls. Clients with metabolic bone problems should not use area rugs at home because they may cause tripping or falling.

The nurse plans to refer a client diagnosed with osteoporosis to which community resource?

National Osteoporosis Foundation Clients with musculoskeletal problems should be referred to appropriate community resources, such as the National Osteoporosis Foundation, for help and support for their diagnosis.

A client has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon?

Paresis of right lower extremity Paresis indicates a neurovascular compromise that must be reported immediately to the surgeon

The nurse is assessing a client with Ewing's sarcoma. Which finding does the nurse expect to observe?

Leukocytosis Ewing's sarcoma is a malignant tumor, and the client may experience systemic manifestations, including leukocytosis, anemia, and low-grade fever.

A client has been prescribed denosumab (Prolia). What instruction about this drug is most appropriate?

Make appointments to come get your shot Denosumab is given by subcutaneous injection twice a year.

A client is admitted with a large draining wound on the leg. What action does the nurse take first?

Obtain cultures of the leg wound. The nurse first obtains wound cultures prior to administering broad-spectrum antibiotics. The nurse would need to start the IV prior to giving the antibiotics as they will most likely be parenteral. Pain should be treated but that is not the priority.

Which symptom specifically in older patients presenting with acute osteomyelitis would require immediate nursing intervention?

Pain Rationale: Common presenting symptoms of osteomyelitis are pain, fever, edema, elevated leukocyte count, fatigue, and general malaise. However, older adults may not have an extreme temperature elevation because of lower core body temperature and compromised immune system that occur with normal aging

The nurse is caring for a client with prostate cancer who has bone metastasis. The nurse anticipates that the health care provider will prescribe which medication?

Pamidronate (Aredia) Pamidronate is a bisphosphonate that is available intravenously and is approved for bone metastasis from the breast, lung, and prostate. Pamidronate protects bones and prevents fractures

The nurse knows that a patient with Paget's disease is at greatest risk for developing which complication?

Pathologic bone fractures Rationale: Pathologic fractures may be the presenting clinical manifestation of the disorder. The femur and the tibia are most often affected, and fracture of these bones can result from minimal trauma. Patients with Paget's disease frequently are fatigued and, although less common, may develop kidney stones, gout, and heart failure.

The nurse is caring for a client with bone cancer of the right hip who has undergone radical resection of the tumor and has received a prosthetic implant. Which client statement indicates effective coping after the procedure?

Physical therapy and counseling will help me adjust to my prosthesis." The client stating that physical therapy and counseling will help him or her to adjust to the prosthesis illustrates effective coping and acceptance.

An older client with diabetes is admitted with a heavily draining leg wound. The client's white blood cell count is 38,000/mm3 but the client is afebrile. What action does the nurse take first?

Place the client on contact isolation. In the presence of a heavily draining wound, the nurse should place the client on contact isolation

A client has a bone density score of -2.8. What action by the nurse is best?

Planning to teach about bisphosphonates A T-score from a bone density scan at or lower than -2.5 indicates osteoporosis. The nurse should plan to teach about medications used to treat this disease. One class of such medications is bisphosphonates.

A nurse is caring for four clients. After the hand-off report, which client does the nurse see first

Post-microvascular bone transfer client whose distal leg is cool and pale This client is the priority because the assessment findings indicate a critical lack of perfusion.

Which is a priority problem for the older adult client diagnosed with bone cancer?

Potential for injury related to weakness and drug therapy Older adult clients are more likely to fall and injure themselves because of weakness and the medications that they are prescribed, especially analgesics.

The nurse suspects that a client may have plantar fasciitis if the client has which assessment finding?

Severe pain in the arch of the foot, especially when getting out of bed Severe pain in the arch of the foot, especially when getting out of bed, is a description of plantar fasciitis.

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.)

Strengthening exercises are important. Take recommended calcium and vitamin D. Walk 30 minutes at least 3 times a week.

A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3 months. What explanation by the nurse is best?

Your feet have less blood flow, so healing is slower The feet are the most distal to the heart and receive less blood flow than other organs and tissues, prolonging the healing time after surgery.

What is the primary role of the nurse when caring for an adult client with muscular dystrophy (MD)?

Supportive care Management of the client with MD is supportive and involves the entire health care team.

The nurse is instructing a client who has been prescribed calcium citrate (Citracal). Which instruction does the nurse include?

Take Citracal with food. Calcium supplements can cause gastric upset; taking Citracal with food can minimize gastric upset. Calcium citrate should be taken with 6 to 8 ounces of water, not carbonated beverages. One third of the daily dose is best taken at bedtime.

A mother who is a carrier of muscular dystrophy (MD) has a daughter. The client asks the nurse what the daughter's genetic risk is for having MD. What is the nurse's best response

There is a 50% chance that your daughter may carry the gene." MD is an X-linked recessive disorder, so the daughter of a mother who is a carrier has a 50% chance of carrying the gene.

Which finding does the nurse expect to observe in a client with suspected common chronic osteomyelitis?

Ulceration of the skin Ulceration of the skin is a feature of chronic osteomyelitis. Erythema of the affected area; fever; and constant, localized, pulsating bone pain are features of acute osteomyelitis.

A client has an ingrown toenail. About what self-management measure does the nurse teach the client?

Warm moist soaks Treatment of an ingrown toenail includes a podiatrist clipping away the ingrown part of the nail, warm moist soaks, and antibiotic ointment if needed.

The nurse is taking the history of an adult female client. Which factor places the client at risk for osteoporosis?

Working at a desk and playing the piano for a hobby Sedentary lifestyle and prolonged immobility produce rapid bone loss.

The nurse admits a client diagnosed with Paget's disease. The nurse anticipates that the client will have which condition?

enlarged thick skull An enlarged thick skull is a feature of Paget's disease.

Which risk factor is shared by clients who have osteoporosis or osteomalacia?

high alcohol intake High alcohol intake is a risk factor for both osteoporosis and osteomalacia. A history of smoking is a risk factor for osteoporosis only. Inadequate exposure to sunlight and homelessness are risk factors for osteomalacia only.

Which is the best way to decrease the risk for osteoporosis in a client who has just been determined to be at high risk for the disease?

walk 30 min three times a week Walking for 30 minutes three to five times a week is the single most effective exercise for osteoporosis prevention. Walking is a safe way to promote weight bearing and muscle strength