Musculoskeletal NCLEX

A client with osteoarthritis is receiving diclofenac sodium (Voltaren). The licensed practical nurse (LPN) reviewing the client's medication prescription sheet should verify the prescription with the registered nurse (RN) if which other medication is listed?

Warfarin (Coumadin)

A client with a history of spinal cord injury is beginning medication therapy with baclofen (Lioresal). The nurse who is providing medication information should caution the client about which side effect of this medication?

Drowsiness

A client diagnosed with gout has been started on medication therapy with allopurinol (Zyloprim). The nurse reinforces teaching with this client regarding which point about this medication?

"It is important to drink 3 L of fluid per day."

Differentiate between rheumatoid arthritis and OA in terms of joint involvement.

Rheumatoid arthritis occurs bilaterally. OA occurs asymmetrically.

What are the common side effects of salicylates?

GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation

A client with acute muscle spasms has been taking baclofen. The client calls the clinic nurse because of continuous feelings of weakness and fatigue and asks the nurse about discontinuing the medication. The nurse should make which appropriate response to the client?

"Weakness and fatigue commonly occur and will diminish with continued medication use."

When caring for a patient who has osteoarthritis, the nurse will anticipate the need to teach the patient about which of these medications? a. Adalimumab (Humira) b. Prednisone (Deltasone) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

ANS: C Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA.

A nursing assistant is assigned to care for a client who has a CPM machine in place after a total knee arthroplasty. Which statement by the NA indicates a need for further teaching and supervision? A. "I will turn off the machine if the client has any pain." B. "I will turn off the machine when the client wants to eat." C. "I will store the machine on a chair when not used." D. "I will check to make sure the clients leg is correctly placed."

A

Which drug is not appropriate to treat the disease with which it is matched? A. RA-zyloprim B. Osteoarthritis- Celebrex C. Acute gout- colsalide D. Lupus- deltasone

A

A nurse discovers that a client who is in traction for a long bone fracture has a slight fever, is short of breath, and is restless. What does the client most likely have?

A fat embolism, characterized by hypoxemia, respiratory distress, irritability, restlessness, fever and petechiae

Common Manifestations of hip fractures

Ecchymosis and tenderness over the thigh and hip due to bleeding. Groin and hip pain with weight bearing Muscle spasm in the injured area - occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area Shortening of extremity EXTERNALLY ROTATED

Treating Rib Fractures

A single rib fracture is pain management and deep breathing to prevent atelectasis. Multiple rib fractures is higher priority to treat due to possibility of flail chest and respiratory complications

Which assessment finding about a patient who has been using naproxen (Naprosyn) for 3 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider? a. The patient has dark colored stools. b. The patient's pain has not improved. c. The patient is using capsaicin cream (Zostrix). d. The patient has gained 3 pounds over 3 weeks.

ANS: A Dark colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by the naproxen. The information about the patient's ongoing pain and weight gain also will be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

To determine whether a patient with joint swelling and pain has systemic lupus erythematosus, which test will be most useful for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

ANS: C The anti-Sm is antibody found almost exclusively in SLE. The other blood tests also are used in screening but are not as specific to SLE.

List three of the most common joints that are replaced.

Hip, knee, finger

Calcium Administration

Calcium and Vitamin D are essential for bone strength. Calcium absorption is IMPAIRED if taken in excess so it needs to be divided in less than 500 mg per dose.

Tumor Necrosis Factor Inhibitors (3)

Infliximab Adalimumab Etanercept Suppress the inflammatory response in autoimmune diseases such as Rheumatoid Arthritis, Crohn's and psoriasis. Due to immunosuppression clients are at risk for infection. A patient with a current, recent, or chronic infection SHOULD NOT take.

Allopurinol

Medication given for prevention of gout. It can take several months to become effective. Gout is the buildup of uric acid deposited in the joints that causes pain and inflammation. Should take with a glass of water and increase daily fluid intake to prevent kidney stones. Can also take with food or following a meal ANY RASH SHOULD BE REPORTED IMMEDIATELY AND CLIENT STOPS MEDICATION. Can lead to steven johnsons syndrome (Super anaphlyaxis)

Identify the categories of drugs commonly used to treat arthritis.

NSAIDs, of which salicylates are the cornerstone of treatment, and corticosteroids (used when arthritic symptoms are severe).

Methotrexate

Nonbiologic Disease-modifying antirheumatic drug used for RHEUMATOID ARTHRITIS. Adverse effects include bone marrow suppression, hepatotoxicity, and GI irritation Bone marrow suppression can lead to anemia, leukopenia, and thrombocytopenia. Anemia leads to fatigue, dyspnea on EXERTION, and pallor. Leukopenia increases risk for infection Thrombocytopenia presents as petechiae, purpura, or bleeding. Stomatitis (Inflammation of the mouth, oral ulcers) is a common side effect

What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition?

Notify physician state, draw blood gases, administer O2 according to blood gas results, assist with endotracheal intubation and treatment of respiratory failure

Carpal tunnel

Pain and paresthesia over the first 3.5 fingers.

The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client?

Uric acid level of 8 mg/dL

Joint dislocation

Orthopedic EMERGENCY due to the possibility of severe complications. Acute pain, joint deformity, decreased R.O.M and extremity numbness (paresthesia) When the joint is dislocated, the articular tissues, blood vessels and nerves are often stretched and torn. Ischemia from disruption in blood supply may threaten the limb.

List three nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems.

Passive ROM exercises; elastic stockings; elevation of foot of bed 25 degrees to increase venous return

Baclofen (Lioresal) is prescribed for a client with a spinal cord injury who is experiencing muscle spasms, and the nurse prepares a list of the associated side effects of the medication and reviews the list with the client. Which side effect identified by the client indicates a need for further teaching?

Photosensitivity

The nurse obtains this information when assessing a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis. Which symptom is most important to report to the health care provider? a. Abdominal cramping b. Complaint of blurry vision c. Phalangeal joint tenderness d. Blood pressure 170/84 mm Hg

ANS: B Plaquenil can cause retinopathy; the medication should be stopped. The other findings are not related to the medication, although they also will be reported.

What measures should the nurse encourage female clients to take to prevent osteoporosis?

Possible estrogen replacement after menopause, high calcium and vitamin D intake beginning in early adulthood, calcium supplements after menopause, and weight-bearing exercise

A licensed practical nurse (LPN) is told that baclofen (Lioresal) is prescribed for an assigned client. The LPN questions the registered nurse about the health care provider's prescription if which condition is noted on the client problem list?

Seizure disorder

Anakinra (Kineret) is prescribed for a patient who has rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. self-administration of subcutaneous injections. b. taking the medication with at least 8 oz of fluid. c. avoiding concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs). d. symptoms of gastrointestinal (GI) irritation or bleeding.

ANS: A Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or NSAIDs, and these should not be discontinued.

After teaching a patient diagnosed with progressive systemic sclerosis about health maintenance activities, the nurse determines that additional instruction is needed when the patient says, a. "I should lie down for an hour after meals." b. "Paraffin baths can be used to help my hands." c. "Lotions will help if I rub them in for a long time." d. "I should perform range-of-motion exercises daily."

ANS: A Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective.

A patient with an acute attack of gout is treated with colchicine. The nurse determines that the drug is effective upon finding a. relief of joint pain. b. increased urine output. c. elevated serum uric acid. d. decreased white blood cells (WBC).

ANS: A Colchicine produces pain relief in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day would increase urine output but would not indicate the effectiveness of colchicine. Elevated uric acid levels would result in increased symptoms. The WBC count might decrease with decreased inflammation, but this would not be as useful in determining the effectiveness of colchicine as a decrease in pain.

A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing a side effect of the medication? a. The patient's blood glucose is 165 mg/dL. b. The patient has no improvement in symptoms. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.

ANS: A Corticosteroids have the potential to cause diabetes mellitus. The finding of an elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication

Which statement by a 24-year-old woman with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurse's teaching about management of the condition? a. "I will use a sunscreen whenever I am outside." b. "I will try to keep exercising even if I am tired." c. "I should take birth control pills to keep from getting pregnant." d. "I should not take aspirin or nonsteroidal anti-inflammatory drugs."

ANS: A Severe skin reactions can occur in patients with SLE who are exposed to the sum. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal anti-inflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with a. a warm bath followed by a short rest. b. a short routine of isometric exercises. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

ANS: A Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

A patient who had arthroscopic surgery of the left knee 5 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? a. The blood pressure is 88/46 mm Hg. b. The white blood cell count is 14,200/µL. c. The patient is taking ibuprofen (Motrin). d. The patient says the knee is very painful.

ANS: A The low blood pressure suggests that the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and also should be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

Which information will the nurse include when teaching range-of-motion exercises to a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Application of cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

ANS: B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints as well as improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

A patient with dermatomyositis is receiving long-term prednisone (Deltasone) therapy. Which assessment finding by the nurse is most important to report to the health care provider? a. The blood glucose is 112 mg/dL. b. The patient has painful hematuria. c. The patient has an increased appetite. d. Acne is noted on the back and face.

ANS: B Corticosteroid use is associated with increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne also are adverse effects of corticosteroid use, but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

Which information will the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about the management of the condition? a. Exercise by taking long walks. b. Do daily deep breathing exercises. c. Sleep on the side with hips flexed. d. Take frequent naps during the day.

ANS: B Deep breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

Which finding will the nurse expect when assessing a 60-year-old patient who has osteoarthritis (OA) of the left knee? a. Heberden's nodules b. Pain upon joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

ANS: B Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA), and stiffness in OA is worse right after the patient rests and decreases with joint movement.

A patient has systemic sclerosis manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep patient's room warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

ANS: B Keeping the room warm will decrease the incidence of Raynaud's phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose levels or to assist the patient to the bathroom every 2 hours.

The health care provider has prescribed the following collaborative interventions for a 49-year-old who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Use naproxen (Aleve) 200 mg BID. d. Take famotidine (Pepcid) 20 mg daily.

ANS: B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

A patient with gout tells the nurse that he takes losartan (Cozaar) for control of the condition. The nurse will plan to monitor a. blood glucose. b. blood pressure. c. erythrocyte count. d. lymphocyte count.

ANS: B Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cell count (RBC), or lymphocytes.

After obtaining the health history from a 28-year-old woman who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information about the patient is most important for the nurse to report to the health care provider? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to have a baby before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

ANS: B Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

A 22-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. has a parent who has reactive arthritis. b. is sexually active and has multiple partners. c. recently returned from a trip to South America. d. had several sports-related knee injuries as a teenager.

ANS: B Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.

After the nurse has finished teaching a patient with osteoarthritis (OA) of the left hip and knee about how to manage the OA, which patient statement indicates a need for more education? a. "I can take glucosamine to help decrease my knee pain." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."

ANS: B No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management.

When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to a. stand rather than sit when performing household chores. b. avoid activities that require continuous use of the same muscles. c. strengthen small hand muscles by wringing sponges or washcloths. d. protect the knee joints by sleeping with a small pillow under the knees.

ANS: B Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion (ROM).

When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus (SLE), which result is most important to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

ANS: B The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process.

A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate? a. "You may need to see a family therapist for some help." b. "Tell me more about the situations that are causing stress." c. "Perhaps it would be helpful for you and your family to get involved in a support group." d. "Your family may need some help to understand the impact of your rheumatoid arthritis."

ANS: B The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

A patient hospitalized with polymyositis has joint pain, an erythematosus facial rash with eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is a. acute pain related to inflammation. b. risk for aspiration related to dysphagia. c. risk for impaired skin integrity related to scratching. d. disturbed visual perception related to eyelid swelling.

ANS: B The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other nursing diagnoses also are appropriate but are not as high a priority as the maintenance of the patient's airway.

When caring for a patient with a new diagnosis of rheumatoid arthritis, which action will the nurse include in the plan of care? a. Instruct the patient to purchase a soft mattress. b. Teach patient to use lukewarm water when bathing. c. Suggest that the patient take a nap in the afternoon. d. Suggest exercise with light weights several times daily.

ANS: C Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress.

When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information is most important to communicate to the health care provider? a. The blood glucose is 75 mg/dL. b. The rheumatoid factor is positive. c. The white blood cell (WBC) count is 1500/L. d. The erythrocyte sedimentation rate is elevated.

ANS: C Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in rheumatoid arthritis. The blood glucose is normal.

Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. Which laboratory result will the nurse monitor to determine whether the medication has been effective? a. Blood glucose test b. Liver function tests c. C-reactive protein level d. Serum electrolyte levels

ANS: C C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels also will be monitored to check for side effects of prednisone. Liver function is not routinely monitored for patients receiving steroids.

A patient with rheumatoid arthritis refuses to take the prescribed methotrexate (Rheumatrex), telling the nurse "That drug has too many side effects. My arthritis isn't that bad yet." The most appropriate response by the nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

ANS: C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

Which of these patients seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)? a. A 56-year-old man who is a member of a construction crew b. A 24-year-old man who participates in a summer softball team c. A 49-year-old woman who works on an automotive assembly line d. A 36-year-old woman who is newly diagnosed with diabetes mellitus

ANS: C OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve nonrepetitive work and thus would not be as risky

A 26-year-old patient with urethritis and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with a. anakinra (Kineret). b. etanercept (Enbrel). c. doxycycline (Vibramycin). d. methotrexate (Rheumatrex).

ANS: C Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis.

A patient who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that rheumatoid nodules are present on the patient's elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injection of the nodule. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodule.

ANS: C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence

When caring for a patient with gout and a red and painful left great toe, which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the left foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach patient to avoid use of acetaminophen (Tylenol).

ANS: C Since any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by the urate crystals. Acetaminophen can be used for pain relief.

While working at a summer camp, the nurse notices a circular lesion with a red border and clear center on the arm of a patient who is in the camp clinic complaining of chills and muscle aches. Which action should the nurse take next? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.

ANS: C The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest cardiac or abdominal problems or lack of immunization.

A home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes. Which action by the nurse is most appropriate? a. Reassure the patient that dry eyes are a common problem with RA. b. Teach the patient more about adverse affects of the RA medications. c. Suggest that the patient start using over-the-counter (OTC) artificial tears. d. Ask the health care provider about lowering the methotrexate (Rheumatrex) dose.

ANS: C The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself.

A patient with an acute attack of gout in the left great toe has a new prescription for probenecid (Benemid). Which information about the patient's home routine indicates a need for teaching regarding gout management? a. The patient sleeps about 8 to 10 hours every night. b. The patient usually eats beef once or twice a week. c. The patient generally drinks about 3 quarts of juice and water daily. d. The patient takes one aspirin a day prophylactically to prevent angina.

ANS: D Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

A long-term care patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of a. sertraline (Zoloft). b. famotidine (Pepcid). c. oxycodone (Roxicodone). d. hydrochlorothiazide (HydroDIURIL).

ANS: D Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.

The home health nurse is doing a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed? a. The patient requires a 2-hour midday nap. b. The patient has been taking 16 aspirins daily. c. The patient sits on a stool when preparing meals. d. The patient sleeps with two pillows under the head.

ANS: D The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective.

A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I hate the way I look! I never go anywhere except here to the health clinic." An appropriate nursing diagnosis for the patient is a. activity intolerance related to fatigue and inactivity. b. impaired social interaction related to lack of social skills. c. impaired skin integrity related to itching and skin sloughing. d. social isolation related to embarrassment about the effects of SLE.

ANS: D The patient's statement about not going anywhere because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

What is the priority nursing intervention used with clients taking NSAIDs?

Administer or teach clients to take drugs with food or milk.

5. When taking a patient history during assessment of the musculoskeletal system, the nurse identifies an increased risk for the patient who reports a. that a parent became much shorter with aging. b. a sprained ankle 2 years previously. c. a family history of tuberculosis. d. taking over-the-counter (OTC) ibuprofen (Advil) for occasional aches.

Answer: A Rationale: A family history of height loss with aging may indicate osteoporosis, and the patient may need to consider preventative actions, such as calcium supplements. A sprained ankle 2 years previously will not cause any current or future musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk. Cognitive Level: Application Text Reference: p. 1621 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

1. Based on the nurse's understanding of the physiology of bone and cartilage, the injury that the nurse would expect to heal most rapidly is a a. fracture of the midhumerus. b. torn knee cruciate ligament. c. fractured nose. d. severely sprained ankle.

Answer: A Rationale: Bone is dynamic tissue that is continually growing. Nasal fracture, sprains, and ligament tears injure cartilage, tendons, and ligaments, which are slower to heal. Cognitive Level: Application Text Reference: p. 1615 Nursing Process: Assessment NCLEX: Physiological Integrity

11. A patient suffers an injury to the shoulder while playing football. To identify abnormalities of cartilage and soft tissue surrounding the joint, the nurse would expect the patient to be evaluated with a. radioisotope bone scanning. b. arthroscopy. c. standard x-rays. d. magnetic resonance imaging (MRI).

Answer: D Rationale: MRI is most useful in assessing for soft tissue injuries. Bone scanning and standard radiographs are used to assess for injures or lesions of bone. Arthroscopy is used for visualizing the joints. Cognitive Level: Comprehension Text Reference: p. 1625 Nursing Process: Assessment NCLEX: Physiological Integrity

10. A patient is seen at the urgent care center following a blunt injury to the left knee. The knee is grossly swollen and very painful, but the skin is intact. During an arthrocentesis on the patient's knee, the nurse would expect the aspirated fluid to appear a. sanguineous. b. purulent and thick. c. straw colored. d. white, thick, and ropelike.

Answer: A Rationale: The patient's clinical manifestations suggest hemarthrosis, and the appearance of blood in the synovial fluid is expected. Purulent fluid occurs when there is a joint infection. Straw-colored fluid is normal and will not be expected when the knee is swollen and painful. Thick fluid suggests infection. Cognitive Level: Comprehension Text Reference: p. 1628 Nursing Process: Assessment NCLEX: Physiological Integrity

6. Which information obtained during the nurse's assessment of the patient's nutritional-metabolic pattern may indicate the risk for musculoskeletal problems? a. The patient is 5 ft 2 in and weighs 180 lb. b. The patient prefers whole milk to nonfat milk. c. The patient dislikes fruits and vegetables. d. The patient takes a multivitamin daily.

Answer: A Rationale: The patient's height and weight indicate obesity, which places stress on weight-bearing joints. The use of whole milk, avoiding fruits and vegetables, and use of a daily multivitamin are not risk factors for musculoskeletal problems. Cognitive Level: Application Text Reference: p. 1621 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

3. When the health care provider tells a patient that the pain in the patient's knee is caused by bursitis, the patient asks the nurse to explain just what bursitis is. The nurse's best response would be to tell the patient bursitis is an inflammation of a. the fibrocartilage that acts as a shock absorber in the knee joint. b. a small, fluid-filled sac found at many joints. c. any connective tissue that is found supporting the joints of the body. d. the synovial membrane that lines the area between two bones of a joint.

Answer: B Rationale: Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa. Cognitive Level: Comprehension Text Reference: p. 1618 Nursing Process: Implementation NCLEX: Physiological Integrity

2. The nurse is assessing the passive range of motion of a patient's shoulder. The patient complains of pain during circumduction when the nurse moves the arm behind the patient. Which question should the nurse ask? a. "Do you ever have trouble making it to the toilet?" b. "Do you have difficulty in putting on a jacket?" c. "Are you able to feed yourself without difficulty?" d. "How well are you able to sleep at night?"

Answer: B Rationale: The patient's pain will make it more difficult to accomplish tasks like putting on a shirt or jacket. This pain should not impact the patient's ability to feed himself or herself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping. Cognitive Level: Application Text Reference: pp. 1620-1622 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

8. While testing the patient's muscle strength, the nurse finds that the patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should documents the patient's muscle strength as level a. 1. b. 2. c. 3. d. 4.

Answer: C Rationale: A level 3 indicates that the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move when gravity is eliminated, and level 4 indicates active movement with some resistance. Cognitive Level: Comprehension Text Reference: p. 1622 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

7. When the nurse is assessing a new patient in the clinic, which information about the patient's medications will be of most concern? a. The patient takes hormone replacement therapy (HRT) to prevent "hot flashes." b. The patient takes a daily multivitamin and calcium supplement. c. The patient has severe asthma and requires frequent therapy with steroids. d. The patient has migraine headaches which are treated with NSAIDs.

Answer: C Rationale: Corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HRT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems. Cognitive Level: Application Text Reference: p. 1619 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

12. A patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DEXA) testing. The nurse will plan to a. start an intravenous line. b. screen the patient for shellfish allergies. c. teach the patient that DEXA is noninvasive. d. give an oral sedative.

Answer: C Rationale: DEXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Because the procedure is painless, no antianxiety medications are required. Cognitive Level: Application Text Reference: p. 1625 Nursing Process: Implementation NCLEX: Physiological Integrity

4. During assessment of the musculoskeletal system of a 74-year-old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit two years ago. The nurse will plan to teach the patient about a. diskography studies. b. magnetic resonance imaging (MRI). c. dual-energy x-ray absorptiometry (DEXA). d. myelographic testing.

Answer: C Rationale: The decreased height and the patient's age suggest that the patient may have osteoporosis and that bone density testing is needed. Diskography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic test for osteoporosis. Cognitive Level: Application Text Reference: pp. 1619, 1625 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

9. When assessing the musculoskeletal system, the nurse's initial action will usually be to a. have the patient move the extremities against resistance. b. feel for the presence of crepitus during joint movement. c. observe the patient's body build and muscle configuration. d. check active and passive range of motion for the extremities.

Answer: C Rationale: The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment of abnormal areas. The other assessments are also included in the assessment but are usually done after inspection. Cognitive Level: Comprehension Text Reference: p. 1621 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

13. A patient has a new order for open magnetic resonance imaging (MRI) to evaluate for right femur osteomyelitis. Which information obtained by the nurse indicates that the nurse should consult with the health care provider before scheduling an MRI? a. The patient is claustrophobic. b. The patient wears a hearing aid. c. The patient is allergic to shellfish. d. The patient has a pacemaker.

Answer: D Rationale: Patients with permanent pacemakers cannot have MRI. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Contrast medium will not be used, so shellfish allergy is not a contraindication to MRI. Cognitive Level: Application Text Reference: p. 1625 Nursing Process: Assessment NCLEX: Physiological Integrity

Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need for further teaching by the nurse? A. "I need to eat more green, leafy veggies and dairy." B. "I will cut down the amount of wine I drink each night." C. "I plan to begin smoking cessation classes at the hospital." D. "I am going to want to work out 3 days/week at the gym."

B

A nurse is performing a musculoskeletal assessment on an older adult. What physiologic changes of aging will the nurse expect? (select all) A. scoliosis B. Muscle Atrophy C. Slowed Movement D. Rheumatoid Arthritis E. Antalgic gait

B,C

A client has a new synthetic arm cast for a radial fracture. What health care teaching does the nurse include for the clients home care? (Select all) A. "Apply heat on the cast for the first 24 hours to increase blood flow for healing." B. "keep your arm elevated, preferably above your heart, as much as possible." C. "Report severe numbness or inability to move your fingers to your physician." D. "Don't cover the cast with anything because it will stay wet for 24 hours."

B,C,D

Which assessment findings will the nurse expect for the client with late stage rheumatoid arthritis (select all) A. Heberdens nodes B. High erythrocyte sedimentation values C. Positive antinuclear antibody titer D. Subcutaneous nodules E. Anemia F. Red, swollen joints

B,C,D,E,F

An older woman had a left total hip arthroplasty yesterday afternoon mom which precautions will the nurse teach before helping the client transfer from the bed to the chair? (Select all) A. "Stand on your left leg and pivot to the chair. " B. "Do not hyper flex your hips when sitting." C. "Cross your legs to be more comfortable." D. "Avoid twisting your body when moving." E. "Use your cane to help move into the chair. "

B,D,E

Describe nursing care for the client who is experiencing phantom pain after amputation.

Be aware that phantom pain is real and will eventually disappear. Administer pain medication; phantom pain responds to medication.

A client returns to PACU after an arthroscopy to repair several knee ligaments. What is the nurse's priority when caring for this client? A. Take vitals every hour B. Check for swelling & bleeding C. Perform frequent neurovascular assessments D. Ensure that the surgical dressing is intact

C

A client who had an elective below-the-knee amputation reports pain in the part of his leg that was amputated. What is the nurse's best response to his pain? A. "the pain will go away in a few days or so." B. "that's phantom limb pain and every amputee has that." C. "on a scale of 0-10, how would you rate your pain?" D. "the pain is not real, so we don't treat it."

C

What health teaching by the nurse is the most important for clients diagnosed with discoid lupus erythematosus and managing the disease using topical steroid cream? A."take calcium supplements to prevent osteoporosis from the steroid. " B. "Stay away from crowds and people with infections." C. "Avoid being in the sun to prevent flare ups." D. "Use heavy powder makeup to cover skin lesions. "

C

The nurse is concerned that a client who had an open reduction, internal fixation of his tibia and fibula is at risk for complex regional pain syndrome. What assessment findings at the affected area are common when a client has this complication? (select all) A. Dull, aching pain B. Decrease in sweating C. Muscle spasms D. Skin discoloration E. paresis F. Edema

C,D,E,F

A client has been taking indomethacin (Indocin) for gout and experiencing side/adverse effects. Which assessment should the nurse expect the health care provider to prescribe?

Checking for occult blood

A client is starting on alendronate (Fosamax) for prevention of osteoporosis. What precaution will the nurse include in the clients health teaching about this drug? A. "Take food or milk to prevent stomach upset." B. "Monitor the drug injection site for redness or itching." C. "Take the drug at night before you go to bed." D. "Do not lie down for at least 30 minutes after the drug."

D

The nurse is caring for a client with Paget's disease of the bone. The nurse understands that the client is receiving calcitonin (Cibacalcin) to produce which effect?

Decrease bone reabsorption.

Baclofen (Lioresal) is prescribed for the client with multiple sclerosis. The nurse evaluates that the medication is having the intended effect if which finding is noted in the client?

Decreased muscle spasms

A client has a new medication prescription for allopurinol (Zyloprim). A practical nursing student co-assigned with the licensed practical nurse (LPN) states, "I know this is for gout, but how does it work?" In formulating a response, the LPN includes that allopurinol works in which manner?

Decreases uric acid production

Describe postoperative residual limb (stump) care (after amputation) for the first 48 hours.

Elevate residua limb for first 24 hours. Do not elevate residual limb after 48 hours. Keep residual limb in extended position, and turn client to prone position three times a day to prevent flexion contractions.

Crutch Paralysis

Excessive and prolonged pressure on the axilla can cause damage to the RADIAL NERVE at the axilla. This manifests as muscle weakness of the arm, wrist, and hand. Main culprit is crutches that are too long and patients supporting body weight in axillae.

Boston Brace, Wilmington Brace, Milwaukee brace

Used to diminish the progression of deformed spinal curves in scoliosis. Braces DO NOT CURE but prevent further worsening. Patients should wear cotton t-shirt under the brace to decrease skin irritation and absorb sweat. The use of lotion or powder can cause skin irritation due to heat buildup under the brace. The exact course of treatment varies but braces are worn for 18-23 hours and taken off during bathing and exercise. NEVER SHOWER WITH BRACE.

List three problems associated with immobility.

Venous thrombosis, urinary calculi, skin integrity problems

Rheumatoid Arthritis Morning Routine

Warm shower or bath immediately after getting out of bed Perform range of motion exercises Eat a balanced breakfast Take NSAID medication

Identify pain relief interventions for clients with arthritis.

Warm, moist heat (compresses, baths, showers); diversionary activities (imaging, distraction, self-hypnosis, biofeedback); and medications.

Ankylosing Spondilitis

inflammatory disease of the spine that has no cause or cure. Stiffness and fusion of the axial joints that lead to restricted spinal mobility. Low back pain and morning stiffness that improve with activity are classic findings. Client with AS should: Promote extension of the spine with proper posture, daily stretching, and swimming/racquet sports Stop smoking and practice breathing to increase chest expansion Manage pain with MOIST HEAT and NSAIDs Take immunosuppressant and anti-infalmmatory meds Sleep on a firm mattress to prevent spinal flexion and deformity