IGGY CH 42: Concepts of Care for Patients With Musculoskeletal Conditions

The nurse is providing health teaching to a postmenopausal client about osteoporosis prevention and screening. Which statement by the client indicates a need for further teaching? A. "I'm planning to have my DXA scan next week because I should get one every year." B. "I signed up for a virtual smoking cessation program with my partner so we can quit together." C. "I joined a group of coworkers who take a walk at lunchtime every day." D. "I'll try to eat more foods high in calcium like dairy products and green leafy vegetables."

A All of the client's statements indicate understanding of the nurse's health teaching except for the frequency of when the client should have a DXA scan to assess bone mineral density. The best practice recommendation is to have a scan every 2 years rather than every year. Therefore, Choice A is the correct response to this question.

The nurse is reviewing the laboratory test results of a client with a recently diagnosed osteosarcoma. What abnormal laboratory finding would the nurse expect for this client? A. Elevated alkaline phosphatase B. Decreased hematocrit C. Increased white blood cell count D. Increased calcium

A An osteosarcoma is a type of primary malignant bone tumor. Alkaline phosphatase is an enzyme that is released from the bone when it is diseased or damaged (Choice A). All of these lab values would be expected in clients who have bone metastasis rather than a single tumor that was recently diagnosed (Choice B, C, and D).

The nurse is teaching a postmenopausal client about the need for bone health and screening. What diagnostic test would the nurse recommend? A. Dual x-ray absorptiometry (DXA) B. Serum calcium and phosphorus C. Vertebral x-rays D. Serum Vitamin D

A The DXA scan screens for bone loss and provides a score to indicate the amount of loss, if any. It is a noninvasive test performed every 2 years to monitor for bone loss as one ages (Choice A). The other tests do not adequately screen bone for tissue loss (Choice B, C, and D).

The nurse is caring for a client who is at risk for osteoporosis. What lifestyle changes might the client be able to implement to decrease this risk? (Select all that apply.) A. Including more calcium-rich foods into the diet B. Avoiding excessive alcohol consumption C. Seeking a smoking cessation program, if needed D. Decreasing consumption of carbonated beverages E. Preventing a sedentary daily lifestyle F. Increasing foods high in phosphorus

A, B, C, D, E All of these lifestyle changes are needed to avoid modifiable risk factors that contribute to the development of osteoporosis except that foods high in phosphorus should be avoided (Choice F). If the serum phosphorous/phosphate level increases, the serum calcium level decreases due to their inverse relationship. Low calcium levels can result in bone loss.

The nurse is caring for a client who is diagnosed with acute osteomyelitis after foot surgery last week. What assessment findings will the nurse expect this client to have? (Select all that apply.) A. Fever usually above 101°F (38.3°C) B. Swelling around the affected area C. Drainage from the affected area D. Sinus tract near surgical incision E. Bone pain that is constant, localized, and pulsating

A, B, E Client findings associated with acute osteomyelitis are similar to those associated with any acute infection, including fever, swelling, and pain (Choice A, B, and E). The development of a sinus tract with drainage is consistent with chronic osteomyelitis (Choice C and D).

The nurse is caring for a client who has MRSA chronic osteomyelitis confirmed by wound culture. What transmission-based precautions would the nurse implement? A. Standard Precautions B. Contact Precautions C. Airborne Precautions D. Droplet Precautions

B MRSA is transmitted by contact and, therefore, the nurse would use the personal protective equipment that would prevent transmission, including gown and gloves (Choice B). Standard precautions would not be sufficient (Choice A). A mask or hair covering is not needed, so Choice C and D are not necessary.

The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the primary health care provider will request which supplement? A. Vitamin C B. Vitamin D3 C. Phosphorus D. Calcium

B 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 (Vitamin D3) (Choice B). Vitamin C is not indicated for the treatment of osteomalacia, which is related to vitamin D deficiency (Choice A). Phosphorus interferes with the absorption of calcium; calcium is not indicated in the treatment of osteomalacia (Choice C and D).

A client is admitted to the same-day surgical center PACU after a traditional open bunionectomy. After assessing the client's ABCs, what is the priority assessment for the client? A. Muscle strength assessment B. Neurovascular assessment C. Joint assessment D. Neurologic assessment

B The client had foot surgery and would have a bulky surgical dressing placed on the area to prevent bleeding. The nurse would want to frequently assess the neurovascular status of the operative foot as the priority (Choice B). The other assessments are not specific to this type of surgery (Choice A, C, and D).

The nurse is planning teaching for an older client who is at risk for osteoporosis. Which of the following modifiable client risk factors would the nurse consider as part of the teaching plan? Select all that apply. A. Older age B. Corticosteroids for lung disease C. Lack of regular exercise D. Parental history of osteoporosis E. Postmenopause F. Food insecurity

B, C, F Modifiable risk factors are those that could be changed or improved. The client's age, family history, and postmenopausal condition cannot be changed and are therefore not the correct responses (Choices A, D, and E). However, the client is on drug therapy that can cause bone loss and needs to be reevaluated (Choice B). The client does not exercise on a regular basis, which the nurse would address as part of health teaching (Choice C). The client's food insecurity could possibly be modified if the client were to use food banks or pantries and other resources (Choice F). Therefore, Choices B, C, and F are correct.

The nurse is caring for a client who has been treated for osteoporosis for 15 years and is starting on denosumab. What health teaching is appropriate for the nurse to include about this drug? A. "Take the drug every morning with a glass of water." B. "Have a dental examination prior to beginning the drug." C. "See your primary health care provider for twice yearly injections." D. "You will receive an IV infusion once a year by your provider."

C Denosumab is a RANKL inhibitor drug administered subcutaneously by a health care professional twice a year, and not given orally or IV (Choice A, C and D). Dental examinations are recommended for clients who are preparing to take bisphosphates, and not needed for this class of drugs (Choice B).

A client who has osteopenia is prescribed to begin risedronate. What health teaching would the nurse include about this drug? A. "Take the drug with dinner or other meal or snack every day." B. "Be sure to follow up with lab work to monitor your liver function." C. "Remain in an upright position for 30 minutes after taking the drug." D. "Be sure to report any new bone pain or infection.

C Risedronate is an oral bisphosphonate that can cause esophagitis. Therefore, the nurse would teach the client to take the drug before breakfast on an empty stomach with a glass of water, and stay in an upright position (sitting or standing) for at least 30 minutes after taking the drug (Choice C). The drug should not be taken at dinner or other meal (Choice A). Risedronate does not typically cause liver damage, new bone pain, or infection (Choice B and D).

The nurse suspects that a client may have plantar fasciitis if the client has which assessment finding? A. Lateral deviation of the great toe; first metatarsal head becomes enlarged B. Dorsiflexion of any metatarsophalangeal (MTP) joint, with plantar flexion of the adjacent proximal interphalangeal (PIP) joint C. Severe pain in the arch of the foot, especially when getting out of bed D. A small tumor in a digital nerve of the foot

C Severe pain in the arch of the foot, especially when getting out of bed, is an indication of plantar fasciitis (Choice C). Lateral deviation of the great toe with an enlarged first metatarsal head describes a bunion of the foot (Choice A). Dorsiflexion of any MTP joint with plantar flexion of the adjacent PIP joint is a description of a hallux valgus and hammertoe of the foot (Choice B). A small tumor in a digital nerve of the foot describes Morton neuroma of the foot (Choice D).

The nurse is planning care for a client who had an osteosarcoma surgically removed from the left lower leg. What is the nurse's priority for immediate postoperative care? A. Monitor for symptoms of wound infection. B. Assess for symptoms of venous thromboembolism. C. Evaluate neurovascular status in the left foot. D. Observe for surgical site bleeding.

C Surgical removal of the bone tumor from the lower leg can cause neurovascular compromise because compartments containing muscle, nerves, and blood vessels are located in the lower part of the legs. Swelling from surgery can compress these vital tissues, causing a decrease in perfusion shortly after surgery or within the first few postoperative days. Therefore the correct response is Choice C. Bleeding from the site could also occur, but the surgeon usually places a large pressure dressing over the area to prevent bleeding (Choice D). Wound infection and venous thromboembolism usually occur several days after surgery and would not be a concern in the immediate postoperative period (Choices A and B).

The nurse is caring for a client who is diagnosed with osteopenia. Which T-score will the nurse expect for this client after a bone mineral density (BMD) test? A. +1.5 B. 0 to ?2-1 C. ?2-2 D. ?2-3

C The T-score represents the standard deviations above or below the average BMD for young, healthy adults. A T-score of ?2-1 to ?2-2.5 represents osteopenia, which is bone loss (Choice C).The T-score in a young, healthy adult is 0. A normal T-score is between +1 and ?2-1 (Choice B). A score of +1.5 is not a part of the T-score (Choice A). A T-score of ?2-3 represents osteoporosis (Choice D).

The nurse is assessing an older client with advanced metastatic bone disease. Which assessment finding would the nurse anticipate as the priority problem? A. Difficulty with ambulation B. Inability to perform ADLs C. Risk for falls due to fragility fracture D. Nausea and vomiting from chemotherapy

C The client may have all of these problems, but the priority is safety. Clients who have metastatic bone disease are at high risk for fragility fracture because of bone mass loss. Fracture can cause a fall, or a fall may cause fracture. Therefore Choice C is the correct response.

A young adult client whose mother and grandmother have osteoporosis asks whether the client needs to take steps to prevent this disease. What will the nurse tell this client? A. "You do not have to worry about symptoms at your age." B. "You should begin to take steps to prevent disease at age 30." C. "Now is the time to begin building strong bones." D. "Your risk isn't present until age 50; we can talk about it then."

C The nurse would tell this client that peak bone mass is achieved by about 30 years of age in most women, so building strong bone as a young person may be the best defense against osteoporosis in later adulthood. The client needs to begin getting adequate calcium and vitamin D now as well as exercising to help build strong bones (Choice C). The nurse will not tell the client not to worry about symptoms at this age (Choice A). Beginning at age 30 may be too late (Choice B). By the time symptoms appear in older adulthood, it is too late to build strong bones (Choice D).

The nurse is caring for a client who has a right wrist ganglion which is interfering with the ability to function as an administrative assistant. What collaborative treatment would the nurse anticipate for this client? A. Intravenous antibiotic therapy B. Physical therapy C. Occupational therapy D. Removal of the ganglion

D Because the ganglion cyst is interfering with the client's ability to work, the ganglion cyst would likely be removed rather than aspirated (Choice D). Antibiotics are not appropriate and rehabilitation is not going to help remove her cyst (Choice A, B, and C).

The nurse is assessing a middle-aged client immediately after a traditional (open) right bunionectomy. Which client finding would the nurse report to the surgeon? A. Right pedal pulse 2+ B. Swelling in right great toe C. 5/10 pain in right great toe D. Right toe capillary refill more than 5 seconds

D Choices A, B, and C are expected assessment findings for a client postoperatively after a traditional bunionectomy. However, capillary refill should be 3 seconds or less for a middle-aged adult and would be reported to the surgeon as a possible indicator of beginning decrease in perfusion to the surgical toe. Therefore Choice D is the correct response.

An older adult client who has osteoporosis is discharged from the hospital. What does the nurse include in health teaching related to the client's home safety? A. "Use area rugs on tile floors." B. "Walk slowly on wet floor areas after mopping." C. "Keep light low to prevent glare." D. "Keep walkways free of clutter."

D The nurse teaches the client that walkways in the home must be clear of clutter and obstacles to help prevent falls. Osteoporosis leads to fragility fractures as a result of severe bone loss (Choice D). Clients with this type of metabolic bone condition should not use area rugs at home because they may cause tripping or falling (Choice A). Clients with osteoporosis should not walk on wet floors because the potential for falling is too great (Choice B). Keeping the lights low would not allow the client to see adequately to walk safely or avoid an object on the floor (Choice C).

What will the nurse recommend as the most appropriate way to decrease the risk for osteoporosis in a client who is at high risk for the disease? A. Increase nutritional intake of calcium. B. Engage in high-impact exercise, such as running. C. Increase nutritional intake of phosphorus. D. Walk for 30 minutes three times a week.

D Walking for 30 minutes three to five times a week is the best and single most effective exercise for osteoporosis prevention (Choice D). Osteoporosis occurs most often in older, women, particularly those who do not exercise regularly. Walking is a safe way to promote weight bearing and muscle strength. A variety of nutrients are needed to maintain bone health, so the promotion of a single nutrient will not prevent or treat osteoporosis (Choice A). High-impact exercise and overtraining, such as running, may cause vertebral compression fractures and should be avoided (Choice B). Calcium loss occurs at a more rapid rate when intake of phosphorus is high; people who drink large amounts of carbonated beverages each day are at high risk for calcium loss and subsequent osteoporosis, regardless of age or gender (Choice C).