Ch. 50 Muscoskeletal Problems

2. A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best? a. Consult with the provider about an x-ray. b. Encourage the client to use ibuprofen (Motrin). c. Have the client perform hip range of motion. d. Place the client in a rigid cervical collar.

ANS: A 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. Motrin may be indicated but not until there is a diagnosis. Range of motion of the hips is not related, although limited spinal range of motion may be found with a vertebral compression fracture. Since the defect is in the thoracic spine, a cervical collar is not needed.

2. Which instruction is most important for the RN to provide to the nursing assistant assigned to care for a client with primary osteoporosis? a. "Clean up clutter in the room." b. "Encourage the client to bathe herself or himself." c. "Monitor urinary output." d. "Perform passive range-of-motion exercises."

ANS: A Clients with osteoporosis are at risk for fracture when they fall. Clutter in the room is a risk factor for falls. The other choices have nothing to do with prevention of bone fracture in a client with primary osteoporosis.

3. 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? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

ANS: A 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. The client may or may not need extra calcium, other exercises, or weight lifting.

16. What information does the nurse teach a women's group about osteoporosis? a. "For 5 years after menopause you lose 2% of bone mass yearly." b. "Men actually have higher rates of the disease but are underdiagnosed." c. "There is no way to prevent or slow osteoporosis after menopause." d. "Women and men have an equal chance of getting osteoporosis."

ANS: A For the first 5 years after menopause, women lose about 2% of their bone mass each year. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.

16. A client is prescribed alendronate (Fosamax). Which statement indicates that the client understands teaching about this drug? a. "I should take this drug with a full glass of water." b. "I need to lie down for 30 minutes after taking it." c. "This drug should be taken after a meal." d. "This drug needs to be taken at the same time as calcium."

ANS: A Fosamax needs to be taken on an empty stomach with a full glass of water for best absorption and to prevent esophagitis. After taking the drug, the client needs to stay upright for 30 minutes. Calcium can be taken, but not at the same time as Fosamax.

6. While caring for a client who has chronic osteomyelitis and wound drainage, which intervention is most important for the nurse to implement? a. Cover the wound with a dressing. b. Teach about the cause of the infection. c. Monitor the erythrocyte sedimentation rate (ESR). d. Prepare the client for hyperbaric oxygenation.

ANS: A If an open wound is present in the hospital or long-term care setting, the client's treatment usually includes Standard Precautions for limiting infection by covering the wound. Teaching about the cause of the infection could prevent further episodes of infection, but does not take care of the current problem. The ESR just tells the health care provider that an inflammatory process is going on. Hyperbaric oxygenation is used only for clients with chronic, unremitting osteomyelitis. Covering the wound would be the most important step for the nurse to take first.

5. Which nursing intervention is most effective in preventing transfer of an organism from the wound of a client with osteomyelitis to other clients? a. Contact Precautions b. Restriction of visitors c. Irrigating the wound as needed d. Leaving the wound open to air

ANS: A In the presence of wound drainage, Contact Precautions may be used to prevent the spread of the offending organism to other clients and health care personnel. Restricting visitors does not prevent transfer. One visitor could possibly transfer the bacteria to another surface. Irrigating the wound would not destroy the organism. The wound should be covered to prevent transfer of the organism.

25. Which client is at highest risk for the development of plantar fasciitis? a. Young adult runner b. Adolescent swimmer c. Older adult client who walks with a cane d. Adult client confined to a wheelchair

ANS: A Plantar fasciitis accounts for 10% of running-related injuries. Obesity is also thought to be a factor in the development of plantar fasciitis. It is often seen in middle-aged and older adults who are ambulatory, but plantar fasciitis is most common in athletes, especially runners.

6. A client in a nursing home refuses to take medications. She is at high risk for osteomalacia. What action by the nurse is best? a. Ensure the client gets 15 minutes of sun exposure daily. b. Give the client daily vitamin D injections. c. Hide vitamin D supplements in favorite foods. d. Plan to serve foods naturally high in vitamin D.

ANS: A Sunlight is a good source of vitamin D, and the nursing staff can ensure some sun exposure each day. Vitamin D is not given by injection. Hiding the supplement in food is unethical. Very few foods are naturally high in vitamin D, but some are supplemented.

14. A client diagnosed with primary bone sarcoma of the leg is scheduled for tumor removal. The client expresses fear of loss of function. Which is the nurse's best response? a. "It is normal to feel this way." b. "Physical therapy will assist you to regain function." c. "This surgery is better than an amputation." d. "This surgery is necessary to save your life."

ANS: A The client with bone cancer is expected to adjust to actual or impending loss with help. An expected outcome of nursing care includes the ability of the client to verbalize the reality of the loss and seek social support. The other responses do not reflect therapeutic communication techniques.

12. A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs? a. Assess the client's coping skills and support systems. b. Explain that the surgery leads to a longer life expectancy. c. Refer the client to the social worker or hospital chaplain. d. Reinforce physical therapy to aid with ambulating normally.

ANS: A 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. Explaining that a limb salvage procedure will extend life does not address the client's psychosocial needs. Referrals may be necessary, but the nurse should assess first. Reinforcing physical therapy is also helpful but again does not address the psychosocial needs of the client.

7. 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? a. Assess the client for leg bowing. b. Facilitate an oncology workup. c. Instruct the client on fluid restrictions. d. Teach the client about ibuprofen (Motrin).

ANS: A This client has manifestations of Paget's disease. The nurse should assess for other manifestations such as bowing of the legs. Other care measures can be instituted once the client has a confirmed diagnosis.

17. A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best? a. Arrange a home safety evaluation. b. Ensure the client has a walker at home. c. Help the client look into assisted living. d. Refer the client to Meals on Wheels.

ANS: A 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. The other options may or may not be needed based upon the client's condition at discharge.

3. Which instruction does the nurse include in the discharge teaching plan of a client who has osteoporosis? a. "Avoid using scatter rugs." b. "Avoid weight-bearing exercises." c. "Use a cane when walking outside." d. "Reduce the amount of protein in your diet."

ANS: A To avoid falls, the client should keep a hazard-free environment, including avoiding scatter rugs, cluttered rooms, and wet floor areas. Weight-bearing exercises help prevent bone resorption. A cane is not needed unless the client has a physical disability. A protein deficiency should be avoided because it might cause a reduction in bone density.

13. 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? a. "Your feet have less blood flow, so healing is slower." b. "The bones in your feet are hard to operate on." c. "The surrounding bones and tissue are damaged." d. "Your feet bear weight so they never really heal."

ANS: A 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. The other explanations are not correct.

2. The nurse is performing a medical history and physical assessment for a client. Which assessment findings lead the nurse to conclude that the client is at risk for development of osteoporosis? (Select all that apply.) a. Client is a white woman with a body mass index (BMI) of 19.4. b. Client fractured her wrist badly in a fall last year. c. Client drinks at least four cans of diet cola every day. d. Client does tai chi exercises for 45 minutes every morning. e. Client has smoked two packs of cigarettes a day for 40 years. f. Client has taken estrogen (Premarin) 0.625 mg daily since menopause.

ANS: A, B, C, E Risk factors for osteoporosis include white race, female gender, small body frame, large intake of caffeinated carbonated drinks, and smoking cigarettes. Recent fracture after a fall indicates that the client's bones may be soft and/or thin. Hormone replacement therapy, late onset of menopause, and regular exercise help reduce the risk of osteoporosis.

5. 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.) a. Assess the daily serum calcium level. b. Consult the provider about a loop diuretic. c. Institute seizure precautions for the client. d. Instruct the client to call for help out of bed. e. Place the client on a 1500-mL fluid restriction.

ANS: A, B, D The client is exhibiting manifestations of possible hypercalcemia. This disorder is treated with increased fluids and loop diuretics. The nurse should assess the calcium level, consult with the provider, and instruct the client to call for help getting out of bed due to possible fractures and weakness. The client does not need seizure precautions or fluid restrictions.

8. A client is suspected to have muscular dystrophy. About what diagnostic testing does the nurse educate the client? (Select all that apply.) a. Electromyography b. Muscle biopsy c. Nerve conduction studies d. Serum aldolase e. Serum creatinine kinase

ANS: A, B, D, E Diagnostic testing for muscular dystrophy includes electromyography, muscle biopsy, serum aldolase and creatinine kinase levels. Nerve conduction is not related to this disorder.

1. 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.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D

ANS: A, B, D, E 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. Fat intake does not contribute to osteoporosis.

6. The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.) a. Draining sinus tracts b. High fevers c. Presence of foot ulcers d. Swelling and redness e. Tenderness or pain

ANS: A, C Draining sinus tracts and foot ulcers are seen in chronic osteomyelitis. High fever, swelling, and redness are more often seen in acute osteomyelitis. Pain or tenderness can be in either case.

4. 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.) a. Adherence to the antibiotic regimen b. Correct intramuscular injection technique c. Eating high-protein and high-carbohydrate foods d. Keeping daily follow-up appointments e. Proper use of the intravenous equipment

ANS: A, C, E The client going home with chronic osteomyelitis will need long-term antibiotic therapy—first intravenous, then oral. The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up.

1. A client has a bone density score of -2.8. What action by the nurse is best? a. Asking the client to complete a food diary b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months

ANS: B 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 food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either.

8. An adult client's susceptibility to osteoporosis is caused by which aspect of his or her history? a. Fractured arm at age 16 b. Active smoking c. Vitamin D supplements d. Weight lifting

ANS: B A history of smoking has been identified as a risk factor for osteoporosis. A history of low-trauma fracture after the age of 50 has been identified as a risk factor. Vitamin D and weight lifting are measures that can be used to prevent this disease.

24. The nurse is caring for a client with a lesion in the area of the tibia that is swollen and tender. Which client problem is the highest priority for nursing care? a. Need for increased calories related to increased metabolism b. Pain management related to physical injury c. Compromised self-care related to weakness d. Safety risk related to skeletal impairment

ANS: B A palpable mass and swelling in the area of the tibia are symptoms of osteochondroma, which is a common, benign bone tumor. Pain is the most common manifestation of a benign bone tumor. The other distractors are important, but pain management is the highest priority.

21. When providing care for a client who has had a débridement for osteomyelitis, which intervention is most important for the nurse to implement? a. Assess the white blood cell count. b. Assess circulation in the distal extremities. c. Administer pain medication. d. Monitor temperature.

ANS: B All the interventions would be completed during care of this client. However, after resection of infected bone, neurovascular assessments must be done frequently because the client experiences increased swelling, which could cause neurovascular compromise.

23. Two hours after limb salvage surgery for a client with left leg bone sarcoma, the nurse notes that the toes of the left foot are more edematous, are cooler to the touch, and have a slower capillary refill. Which action does the nurse take first? a. Apply ice to the distal extremity. b. Check the splint for proper placement. c. Elevate the left foot. d. Loosen the pressure dressing.

ANS: B Assessment of the neurovascular status of the affected extremity should be performed every 1 to 2 hours after surgery. Splinting or casting the limb may cause neurovascular compromise and needs to be checked for proper placement. Applying ice will cause vasoconstriction, which will further impair blood flow. Elevation of the foot will similarly decrease circulation to the area.

13. The mother of a 16-year-old client diagnosed with Ewing's sarcoma expresses concern that her son seems to be angry at everyone in the family. How does the nurse respond? a. "You need to set limits with your son." b. "This is a normal stage in the grieving process." c. "He will be back to normal when he leaves the hospital." d. "This is typical behavior for a teenager."

ANS: B Clients often experience loss of control over their lives when a diagnosis of cancer (e.g., Ewing's sarcoma) is made. Clients may progress through the grieving process, which includes denial, followed by anger. Setting limits without understanding the grieving process can make the client feel that he has no control. The behavior is not typical of a teenager without the disease. It is part of the grieving process. The mother should not expect the son to return to "normal" when he goes home.

5. A client has been prescribed denosumab (Prolia). What instruction about this drug is most appropriate? a. "Drink at least 8 ounces of water with it." b. "Make appointments to come get your shot." c. "Sit upright for 30 to 60 minutes after taking it." d. "Take the drug on an empty stomach."

ANS: B Denosumab is given by subcutaneous injection twice a year. The client does not need to drink 8 ounces of water with this medication as it is not taken orally. The client does not need to remain upright for 30 to 60 minutes after taking this medication, nor does the client need to take the drug on an empty stomach.

26. The nurse is caring for a client with rheumatoid arthritis. For which condition does the nurse assess most carefully? a. Dupuytren's contracture b. Hallux valgus c. Morton's neuroma d. Plantar fasciitis

ANS: B Hallux valgus deformity is a common foot problem in which the great toe deviates laterally at the first metatarsophalangeal joint. This condition often occurs as a result of poorly fitted shoes, family history, osteoarthritis, and rheumatoid arthritis. The other responses are not applicable to rheumatoid arthritis.

15. A client newly diagnosed with Ewing's sarcoma is most likely to exhibit which laboratory finding? a. Elevated red blood cells (RBCs) b. Elevated alkaline phosphatase (ALP) c. Decreased erythrocyte sedimentation rate (ESR) d. Decreased serum lactate dehydrogenase (LDH)

ANS: B In Ewing's sarcoma, laboratory results typically would demonstrate elevated alkaline phosphatase because of higher osteoblastic activity. Red blood cells would be low indicating anemia, the ESR would be elevated owing to tissue inflammation, and the LDH would be elevated as the cancer progresses.

17. A client is seen at the clinic with the medical diagnosis of osteomalacia. When taking the client's history, what does the nurse assess for? a. Arm and leg strength b. Dietary intake of vitamin D c. Dietary intake of calcium d. Exercise habits

ANS: B Vitamin D deficiency is the most important factor in the development of osteomalacia. Weak arm and leg strength may be seen, calcium deficiency plays a part in the disease process, and discomfort while exercising may be described. However, the most significant risk factor in this disease process is vitamin D deficiency.

7. Which exercise does the nurse recommend to a client at risk for osteoporosis? a. High-impact aerobics 45 minutes once weekly b. Walking 30 minutes three times weekly c. Jogging 30 minutes four times weekly d. Bowling for 1 hour twice weekly

ANS: B Weight-bearing, nonjarring exercises have been proved to reduce or slow bone loss without causing vertebral compression. High-impact aerobics, jogging, and bowling are activities that actually could cause fracture in a client with osteoporosis. Walking would be the best choice as an exercise.

11. A female client who is a carrier of the gene for Duchenne's muscular dystrophy asks whether any of her daughters will have this disease. Which is the nurse's best response? a. "Both parents must have the defective gene." b. "Your daughter cannot get the disease." c. "Your daughters have a 50% chance of developing the disease." d. "Your daughters will become carriers of the gene."

ANS: B Women who are carriers have a 50% chance of passing the gene to their daughter, who then are carriers, and to their sons, who then have the disease. This type of muscular dystrophy affects only males. The other responses are not accurate.

14. A client has scoliosis with a 65-degree curve to the spine. What action by the nurse takes priority? a. Allow the client to rest in a position of comfort. b. Assess the client's cardiac and respiratory systems. c. Assist the client with ambulating and position changes. d. Position the client on one side propped with pillows.

ANS: B This degree of curvature of the spine affects cardiac and respiratory function. The nurse's priority is to assess those systems. Positioning is up to the client. The client may or may not need assistance with movement.

3. 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.) a. Administering ibuprofen (Motrin) b. Applying a heating pad c. Providing a massage d. Referring the client to a support group e. Using a bed cradle to lift sheets off the feet

ANS: B, C Comfort measures for Paget's disease include heat and massage. Administering medications and referrals are done by the nurse. A bed cradle is not necessary.

1. The nurse reviews the health history of a client with acute osteomyelitis. Which findings might have contributed to the diagnosis? (Select all that apply.) a. Recent dental work b. Urinary tract infection c. Pregnancy d. Age e. Hemodialysis f. Gastrointestinal infection

ANS: B, E, F Poor dental hygiene and gum infection (not necessarily recent dental work), urinary tract infection, hemodialysis, and Salmonella infection of the gastrointestinal tract can be sources of infection and, consequently, osteomyelitis. Pregnancy and advancing age are not necessarily precursors to osteomyelitis, even though urinary tract infection leading to osteomyelitis is common in older men.

10. A client's susceptibility to osteomalacia is related to which risk factor? a. Calcium level of 11 mg/dL b. Diet high in milk and soy c. Phosphate level of 1.0 mg/dL d. Taking vitamin D supplements

ANS: C A low serum phosphate level predisposes a client to osteomalacia. The normal range is 2.5 to 4.5 mg/dL. Vitamin D supplements, diets high in vitamin D (e.g., milk and soy), and high calcium levels are not risk factors for osteomalacia.

11. A hospitalized client is being treated for Ewing's sarcoma. What action by the nurse is most important? a. Assessing and treating the client for pain as needed b. Educating the client on the disease and its treatment c. Handling and disposing of chemotherapeutic agents per policy d. Providing emotional support for the client and family

ANS: C All actions are appropriate for this client. However, for safety, the nurse should place priority on proper handling and disposal of chemotherapeutic agents.

10. A client has a metastatic bone tumor. What action by the nurse takes priority? a. Administer pain medication as prescribed. b. Elevate the extremity and apply moist heat. c. Handle the affected extremity with caution. d. Place the client on protective precautions.

ANS: C Bones invaded by tumors are very fragile and fracture easily. For client safety, the nurse handles the affected extremity with great care. Pain medication should be given to control pain. Elevation and heat may or may not be helpful. Protective precautions are not needed for this client.

8. 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? a. Administer acetaminophen (Tylenol). b. Educate the client on amputation. c. Place the client on contact isolation. d. Refer the client to the wound care nurse.

ANS: C In the presence of a heavily draining wound, the nurse should place the client on contact isolation. If the client has discomfort, acetaminophen can be used, but this client has not reported pain and is afebrile. The client may or may not need an amputation in the future. The wound care nurse may be consulted, but not as the first action.

27. The nurse is assessing a client with Paget's disease. Which assessment finding leads the nurse to notify the health care provider immediately? a. Client is 5 feet in height and weighs 130 pounds. b. Long bones of the legs and arms are bowing. c. Base of the skull is enlarged with changes in vital signs. d. Mild pain is present in the area of the hips and pelvis.

ANS: C It is common for the client with Paget's disease to be short in stature and to develop bowing of the long bones and mild to moderate pain, which often occurs in weight-bearing joints. When the skull becomes enlarged with basilar invagination, the brainstem may become damaged; this can threaten the vital sign center and life itself.

15. A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first? a. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago b. Client taking ibandronate (Boniva) who cannot remember when the last dose was c. Client taking raloxifene (Evista) who reports unilateral calf swelling d. Client taking risedronate (Actonel) who reports occasional dyspepsia

ANS: C 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 client with flank pain may have had a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications.

18. A client is scheduled for a bone biopsy. What action by the nurse takes priority? a. Administering the preoperative medications b. Answering any questions about the procedure c. Ensuring that informed consent is on the chart d. Showing the client's family where to wait

ANS: C 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 provider should answer questions about the procedure. The nurse does show the family where to wait, but this is not the priority and could be delegated.

9. A nurse is caring for four clients. After the hand-off report, which client does the nurse see first? a. Client with osteoporosis and a white blood cell count of 27,000/mm3 b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT

ANS: C This client is the priority because the assessment findings indicate a critical lack of perfusion. A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific postprocedure care.

2. 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.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week.

ANS: C, D, E Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day.

7. The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.) a. Antianxiety agents b. Antibiotics c. Barbiturates d. Corticosteroids e. Loop diuretics

ANS: C, D, E Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with the formation of osteoporosis.

4. The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL b. Client who recently fell and has vertebral compression fractures c. Hypertensive client who takes calcium channel blockers d. Client with a spinal cord injury who cannot tolerate sitting up

ANS: D 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. Poor renal function also makes clients bad candidates for this drug, but the client with a creatinine of 0.8 mg/dL is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.

9. Which client does the nurse assess more carefully for risk of developing primary osteoporosis? a. African-American client b. Resident of a nursing home c. Client who eats meat with every meal d. Client who drinks 6 cups of coffee daily

ANS: D Excessive consumption of caffeine and alcohol has been shown to be a risk factor for primary osteoporosis because of loss of calcium in the urine. Being white or Asian has been identified as causing a higher risk for developing osteoporosis at an earlier age compared with African-American ethnicity. Being a resident of a nursing home who is not exposed to sunlight could be a risk factor, but just being a resident does not predispose to osteoporosis. Meat is high in protein. Protein deficiency has been identified as a risk factor.

20. Which assessment finding relates most directly to a diagnosis of chronic osteomyelitis? a. Erythema of the affected area b. Swelling around the affected area c. Temperature higher than 101° F (38° C) d. Ulceration of the skin

ANS: D Fever, swelling, and erythema are far less common in chronic osteomyelitis, whereas ulceration, sinus tract formation, and localized pain are more characteristic.

12. When preparing to care for a client with a family history of Paget's disease, it is most important for the nurse to include education in which area? a. Avoidance of infections b. Exercise program c. Nutrition high in vitamin C d. Need for genetic testing

ANS: D Paget's disease has been noted in up to 30% of people with a positive family history. Clients who have a history of this disease in their family should be taught the importance of genetic counseling. An exercise program may be started with the help of a physical therapist, but exercise may be difficult because of pain and danger of fracture. The diet should be rich in calcium and vitamin D.

18. The nurse has educated a client on Paget's disease. Which statement by the client indicates good understanding of causative factors? a. "It is caused by lack of calcium in my diet." b. "I probably had a fracture that caused it." c. "This disease occurs because of lack of exercise." d. "I may have a genetic predisposition."

ANS: D Paget's disease has been noted in up to 30% of people with a positive family history. The other responses are not accurate as a cause of Paget's disease.

1. The RN has assigned a client with severe osteoporosis to an LPN. Which information about the care of the client is most important for the RN to provide the LPN? a. Provide passive range of motion (ROM) to all weight-bearing joints. b. Position the client upright to promote lung expansion. c. Place a pillow between the client's knees when in the side-lying position. d. Use a lift sheet to reposition the client.

ANS: D Severe osteoporosis causes such bone density loss that pathologic fractures can easily occur when lifting or pulling a client. Use of a lift sheet when positioning reduces this risk. Passive range of motion prevents contractures, but active weight-bearing exercise reduces bone resorption and is a better choice if possible. Positioning the client to promote lung expansion and positioning with a pillow for side-lying are important interventions for any client. The most important intervention for this client is to prevent bone fractures.

19. A client is admitted with a large draining wound on the leg. What action does the nurse take first? a. Administer ordered antibiotics. b. Insert an intravenous line. c. Give pain medications if needed. d. Obtain cultures of the leg wound.

ANS: D 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.

19. A client has severe Paget's disease. Which factor has the highest priority when the nurse intervenes in the care of this client? a. Dietary education b. Exercise program c. Genetic testing d. Relief of pain

ANS: D The primary intervention for Paget's disease is drug therapy with pain management as a priority. This can be accomplished with various drugs and complementary measures. All the other options are treatments for Paget's disease. Pain management is the priority.

20. A client has an ingrown toenail. About what self-management measure does the nurse teach the client? a. Long-term antibiotic use b. Shoe padding c. Toenail trimming d. Warm moist soaks

ANS: D Treatment of an ingrown toenail includes a podiatrist clipping away the ingrown part of the nail, warm moist soaks, and antibiotic ointment if needed. Antibiotics are not used long-term. Padding the shoes will not treat or prevent ingrown toenails. Clients should not attempt to trim ingrown nails themselves.

22. A client who has been diagnosed with osteomyelitis is beginning antibiotic therapy. Which information does the nurse include in the client's teaching plan? a. Needing a consultation with a surgeon b. Continuing on Contact Isolation at home c. Remaining in the hospital for the rest of the treatment d. Receiving antibiotic treatment at home from the home health nurse

ANS: D Typically, osteomyelitis requires treatment with IV antibiotics for several weeks. The client will leave the hospital with a central IV catheter (PICC) for home infusion of the medication. Oral antibiotics usually follow the IV regimen for several more weeks. Surgical intervention is reserved for clients with chronic osteomyelitis if medication therapy is ineffective. Contact Isolation is needed only if the infection can be transmitted to another person when copious drainage is present.

4. After the administration of each dose of zoledronic acid (Zometa), it is most important for the nurse to determine which finding? a. Capillary refill b. Pain relief c. Level of consciousness d. Urine output

ANS: D Zoledronic acid is a bisphosphonate that helps protect bones and prevent fractures. Urine output and serum creatinine should be monitored because this drug can be toxic to the kidneys. Zometa does not relieve pain or affect capillary refill or level of consciousness.