Chapter 42: Management of Patients With Musculoskeletal Disorders

When performing a physical assessment of a client, the client reports numbness, tingling, and pain when the nurse percusses lightly over the median nerve. The nurse recognizes that this finding is consistent with: a) Carpal tunnel syndrome b) Dupuytren's contracture c) Impingement syndrome d) Morton's neuroma

A (Carpal tunnel syndrome Explanation: Tinel's sign (numbness, tingling, and pain in response to light percussion over the median nerve) is a positive finding for carpal tunnel syndrome. pg.1136)

A client is diagnosed with osteomyelitis. This is most commonly caused by which of the following? a) Staphylococcus aureus b) Psuedomonas aeruginosa c) Escherichia coli d) Proteus vulgaris

A (Staphylococcus aureus Explanation: Staphylococcus aureus causes over 50% of bone infections. Other organisms include Proteus vulgaris and Pseudomonas aeruginosa, as well as E. coli. pg.1148)

A nurse is planning discharge teaching regarding exercise for a client at risk for osteoporosis. Which of the following exercises would be appropriate? a) Walking b) Yoga c) Bicycling d) Swimming

A (Walking Explanation: Weight-bearing exercises should be incorporated into the client's lifestyle activities. pg.1141)

Ans: B Feedback: Patients with an unstable fracture must have their spine in alignment at all times in order to prevent neurologic damage. This is a greater threat, and higher priority, than promoting function and preventing infection, even though these are both valid considerations. Increased ICP is not a high risk.

A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care? A) Preventing infection B) Maintaining spinal alignment C) Maximizing function D) Preventing increased intracranial pressure

Ans: D Feedback: Signs and symptoms of a traumatic dislocation include acute pain, change in positioning of the joint, shortening of the extremity, deformity, and decreased mobility. A subluxation would cause moderate deformity, or possibly no deformity. A contusion or strain would not cause obvious deformities.

A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. Which of the following is the most plausible explanation for this patients signs and symptoms? A) Subluxated right hip B) Right hip contusion C) Hip strain D) Traumatic hip dislocation

Ans: C Feedback: Subtle personality changes, restlessness, irritability, or confusion in a patient who has sustained a fracture are indications for immediate arterial blood gas studies due to the possibility of fat embolism syndrome. This assessment finding does not indicate an immediate need for electrolyte levels, an ECG, or abdominal ultrasound.

A young patient is being treated for a femoral fracture suffered in a snowboarding accident. The nurses most recent assessment reveals that the patient is uncharacteristically confused. What diagnostic test should be performed on this patient? A) Electrolyte assessment B) Electrocardiogram C) Arterial blood gases D) Abdominal ultrasound

Ans: A, B, C, E Feedback: Older adults are generally vulnerable to falls and have a high incidence of hip fracture. Weak quadriceps muscles, medication effects, vision loss, and slowed reflexes are among the factors that contribute to the incidence of falls. Decreased hearing is not noted to contribute to the incidence of falls.

An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply. A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes D) Hearing loss E) Muscle weakness

The nurse is reviewing the medication administration record of the client. Which of the following medications would lead the nurse to suspect that the client is at risk for osteoporosis? a) penicillamine (Cuprimine) b) raloxifene (Evista) c) plicamycin (Mithracin) d) methotrexate (Rheumatrex)

B (raloxifene (Evista) Explanation: Raloxifene (Evista) is used for the prevention and treatment of osteoporosis. pg.1144)

Which medication classification is prescribed when allergy is a factor causing the skin disorder? a) Antibiotics b) Local anesthetics c) Antihistamines d) Corticosteroids

C (Antihistamines Explanation: Antihistamines are frequently prescribed when an allergy is a factor in causing the skin disorder. They relieve itching and shorten the duration of allergic reaction. Corticosteroids are used to relieve inflammatory or allergic symptoms. Antibiotics are used to treat infectious disorders. Local anesthetics are used to relieve minor skin pain and itching. pg.1040)

Which assessment findings would the nurse expect in a client diagnosed with osteomyelitis? a) Pruritus and uremic frost b) Petechiae over the chest and abnormal ABGs c) Leukocytosis and localized bone pain d) Thrombocytopenia and ecchymosis

C (Leukocytosis and localized bone pain Explanation: Clinical manifestations of osteomyelitis include signs and symptoms of sepsis and localized infection. pg.1148)

Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes? a) Cervical b) Thoracic c) Upper lumbar d) Lower lumbar

D (Lower lumbar Explanation: The lower lumbar disks, L4 to L5 and L5 to S1, are subject to the greatest mechanical stress and greatest degenerative changes. pg.1133)

In chronic osteomyelitis, antibiotics are adjunctive therapy in which of the following situations? a) Wound irrigation b) Vitamin supplements c) Wound packing d) Surgical debridement

D (Surgical debridement Explanation: In chronic osteomyelitis, antibiotics are adjunctive therapy to surgical debridement. pg.1148)

Ans: D Feedback: Greenstick fractures are an incomplete fracture that results in the bone being broken on one side, while the other side is bent. This is not characteristic of an impacted, compound, or compression fracture.

Radiographs of a boys upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture? A) Impacted B) Compound C) Compression D) Greenstick

Ans: B Feedback: The residual limb should not be placed on a pillow, because a flexion contracture of the hip may result. There is no acute need to contact the patients surgeon. Encouraging exercise or transferring the patient does not address the risk of flexion contracture.

The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patients room and finds him resting in bed with his residual limb supported on pillow. What is the nurses most appropriate action? A) Inform the surgeon of this finding. B) Explain the risks of flexion contracture to the patient. C) Transfer the patient to a sitting position. D) Encourage the patient to perform active ROM exercises with the residual limb.

Ans: B Feedback: Placing a pillow between the patients legs when turning prevents adduction and supports the patients legs. Administering analgesics addresses pain but does not directly protect bone remodeling and promote healing. Rotation of the affected leg can cause dislocation and must be avoided. Prone positioning does not need to be maintained at all times.

Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture? A) Administer analgesics as required. B) Place a pillow between the patients legs when turning. C) Maintain prone positioning at all times. D) Encourage internal and external rotation of the affected leg.

The client presents to the emergency department with fever, chills, restlessness, and limited movement of a fractured jaw. The nurse interprets these findings as indicating which of the following complications? a) Osteomyelitis b) Avascular necrosis c) Fat embolism d) Compartment syndrome

A (Osteomyelitis Explanation: Clinical manifestations of osteomyelitis include signs and symptoms of sepsis and localized infection. pg.1148)

Ans: C Feedback: Deep vein thrombosis (DVT) is among the most common complications related to a hip fracture. To prevent DVT, the nurse encourages intake of fluids and ankle and foot exercises. The patient should not be told to endure pain; a proactive approach to pain control should be adopted. While respiratory complications commonly include atelectasis and pneumonia, the use of deep-breathing exercises, changes in position at least every 2 hours, and the use of incentive spirometry help prevent the respiratory complications more than using supplementary oxygen. Bed rest may be indicated in the short term, but is not normally required for 14 days.

A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the following in order to prevent common complications associated with a hip fracture? A) Avoid requesting analgesia unless pain becomes unbearable. B) Use supplementary oxygen when transferring or mobilizing. C) Increase fluid intake and perform prescribed foot exercises. D) Remain on bed rest for 14 days or until instructed by the orthopedic surgeon.

Ans: B Feedback: A second-degree strain involves tearing of muscle fibers and is manifested by notable loss of load- bearing strength with accompanying edema, tenderness, muscle spasm, and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is accompanied by minor edema, tenderness, and mild muscle spasm, without noticeable loss of function. However, this patient states a loss of function. A sprain normally involves twisting, which is inconsistent with the patients overuse injury.

A nurses assessment of a patients knee reveals edema, tenderness, muscle spasms, and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it really hurts to stand up. The nurse should plan care based on the belief that the patient has experienced what? A) A first-degree strain B) A second-degree strain C) A first-degree sprain D) A second-degree sprain

Instructions for the patient with low back pain include that when lifting the patient should a) use a narrow base of support. b) avoid overreaching. c) bend the knees and loosen the abdominal muscles. d) place the load away from the body.

B (Explanation: Instructions for the patient with low back pain should include that when lifting, the patient should avoid overreaching. The patient should also keep the load close to the body, bend the knees and tighten the abdominal muscles, use a wide base of support, and use a back brace to protect the back. When lifting, the patient with low back pain should keep the load close to the body. When lifting, the patient with low back pain should bend the knees and tighten the abdominal muscles. pg.1134)

Which is a risk-lowering strategy for osteoporosis? a) Diet low in calcium and vitamin D b) Increased age c) Smoking cessation d) Low initial bone mass

C (Smoking cessation Explanation: Risk-lowering strategies include increased dietary calcium and vitamin D intake, smoking cessation, alcohol and caffeine consumption in moderation, and outdoor activity. Individual risk factors include low initial bone mass and increased age. A lifestyle risk factor is a diet low in calcium and vitamin D. pg.1141)

A client with osteoporosis is prescribed a selective estrogen receptor modifier (SERM) as treatment. The nurse would identify which drug as belonging to this class? a) Alendronate (Fosamax) b) Calcium gluconate c) Tamoxifen (Nolvadex) d) Raloxifene (Evista)

D (Raloxifene (Evista) Explanation: An example of a selective estrogen receptor modifier (SERM) is raloxifene (Evista). Alendronate is a biphosphonate; calcium gluconate is an oral calcium preparation; tamoxifen is an antiestrogen agent. pg.1144)

Of the following, which is not a risk factor for osteoporosis? a) Being male b) Small-framed, thin White or Asian women c) Being postmenopausal d) Family history

A (Being male Explanation: Being male is not considered a risk factor. The following are some of the risk factors for osteoporosis: being a small-framed, thin White or Asian women; being postmenopausal; family history; inactivity; chronic low calcium intake; and excessive caffeine or tobacco use. pg.1142)

A patient with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. There is no improvement in the wound appearance. What action would the nurse anticipate to promote healing? a) Surgical debridement b) Vitamin supplements c) Wound irrigation d) Wound packing

A (Surgical debridement Explanation: In chronic osteomyelitis, surgical debridement is used when the wound fails to respond to antibiotic therapy. Wound packing, vitamin supplements, and wound irrigation are not the standard of care when treating chronic osteomyelitis. pg.1149)

Ans: B, C, D, F Feedback: Treatment of contusions, strains, and sprains consists of resting and elevating the affected part, applying cold, and using a compression bandage. Massage and corticosteroids are not used to treat these injuries.

A nurse in a busy emergency department provides care for many patients who present with contusions, strains, or sprains. Treatment modalities that are common to all of these musculoskeletal injuries include which of the following? Select all that apply. A) Massage B) Applying ice C) Compression dressings D) Resting the affected extremity E) Corticosteroids F) Elevating the injured limb

Ans: C Feedback: A contusion is a soft-tissue injury that results in bleeding into soft tissues, creating a hematoma and ecchymosis. A sprain is an injury to ligaments caused by wrenching or twisting. A strain is a muscle pull from overuse, overstretching, or excessive stress. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact. Because the injury is not at the site of a joint, the patient has not experienced a sprain, strain, or dislocation.

A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse recognizes that the patient has likely sustained what? A) Sprain B) Strain C) Contusion D) Dislocation

What food can the nurse suggest to the client at risk for osteoporosis? a) Carrots b) Broccoli c) Bananas d) Chicken

B (Broccoli Explanation: Calcium is important for the prevention of osteoporosis. Broccoli is high in calcium. pg.1141)

Which of the following inhibits bone resorption and promotes bone formation? a) Estrogen b) Calcitonin c) Corticosteroids d) Parathyroid hormone

B (Calcitonin Explanation: Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased in osteoporosis. Estrogen, which inhibits bone breakdown, decreases with aging. On the other hand, parathyroid hormone (PTH) increases with aging, increasing bone turnover and resorption. The consequence of these changes is net loss of bone mass over time. Corticosteroids place patients as risk for developing osteoporosis. pg.1143)

The nurse is educating the patient with low back pain about the proper way to lift objects. What muscle should the nurse encourage the patient to maximize? a) Gastrocnemius b) Quadriceps c) Rectus abdominis d) Latissimus dorsi

B (Quadriceps Explanation: The nurse instructs the patient in the safe and correct way to lift objects using the strong quadriceps muscles of the thighs, with minimal use of weak back muscles (Fig. 42-3). pg.1135)

Which of the following is the only selective estrogen receptor modulator approved for osteoporosis in post menopausal women? a) Denosumab b) Forteo c) Raloxifene d) Fosamax

C (Raloxifene Explanation: Raloxifene is the only selective estrogen receptor modulator (SERM) approved for osteoporosis in post menopausal women as it does not increase the risk of breast or uterine cancer, but it does come with an increased risk of thromboembolism. Fosamax is a bisphosphonate. Forteo is a subcutaneously administered medication that is given one daily for the treatment of osteoporosis. Denosumab has recently been approved for treatment of postmenopausal women with osteoporosis who are at risk for fractures. pg.1144)

The nurse is caring for a client following foot surgery. Which nursing intervention is most important for the nurse to include in the nursing care plan? a) Monitor vital signs every 4 hours. b) Administer pain medication per client request. c) Examine surgical dressing every hour. d) Perform neuromuscular assessment every hour.

D (Perform neuromuscular assessment every hour. Explanation: The priority nursing intervention is to perform a neuromuscular assessment every hour. Early detection of neurological and perfusion problems is critical. pg.2061)

Ans: C Feedback: Opioid analgesics may be effective in relieving phantom pain. Heat, immobility, and elevation are not noted to relieve this form of pain.

Six weeks after an above-the-knee amputation (AKA), a patient returns to the outpatient office for a routine postoperative checkup. During the nurses assessment, the patient reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce the discomfort of the phantom pain? A) Apply intermittent hot compresses to the area of the amputation. B) Avoid activity until the pain subsides. C) Take opioid analgesics as ordered. D) Elevate the level of the amputation site.

Ans: A Feedback: Immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the patients bedside so that, if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. PRBCs cannot be kept at the bedside. Vitamin K and protamine sulfate are antidotes to warfarin and heparin, but are not administered to treat active postsurgical bleeding.

The surgical nurse is admitting a patient from postanesthetic recovery following the patients below-the- knee amputation. The nurse recognizes the patients high risk for postoperative hemorrhage and should keep which of the following at the bedside? A) A tourniquet B) A syringe preloaded with vitamin K C) A unit of packed red blood cells, placed on ice D) A dose of protamine sulfate

The nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching? a) "You will receive IV antibiotics for 3 to 6 weeks." b) "Use your continuous passive motion machine (CPM) 2 hours each day." c) "You need to perform weight-bearing exercises twice a week." d) "You need to limit the amount of protein and calcium in your diet."

A ("You will receive IV antibiotics for 3 to 6 weeks." Explanation: Treatment of osteomyelitis requires IV antibiotics for 3 to 6 weeks. pg.1148)

Ans: B Feedback: A compound fracture involves damage to the skin or mucous membranes and is also called an open fracture. A compression fracture involves compression of bone and is seen in vertebral fractures. An impacted fracture occurs when a bone fragment is driven into another bone fragment. A transverse fracture occurs straight across the bone shaft.

A nurse admits a patient who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse is aware that this description likely indicates which type of fracture? A) Compression B) Compound C) Impacted D) Transverse

Ans: C Feedback: An x-ray should be obtained to rule out bone injury, because an avulsion fracture (in which a bone fragment is pulled away from the bone by a tendon) may be associated with a third-degree strain. Nerve damage, compartment syndrome, and greenstick fractures are not associated with third-degree strains.

A patient has presented to the emergency department with an injury to the wrist. The patient is diagnosed with a third-degree strain. Why would the physician order an x-ray of the wrist? A) Nerve damage is associated with third-degree strains. B) Compartment syndrome is associated with third-degree strains. C) Avulsion fractures are associated with third-degree strains. D) Greenstick fractures are associated with third-degree strains.

The nurse is assessing the feet of a patient and observes an overgrowth of the horny layer of the epidermis. What does the nurse recognize this condition as? a) Hammer Toe b) Corn c) Clawfoot d) Bunion

B (Corn Explanation: A corn is an area of hyperkeratosis (overgrowth of a horny layer of epidermis) produced by internal pressure (the underlying bone is prominent because of a congenital or acquired abnormality, commonly arthritis) or external pressure (ill-fitting shoes). The fifth toe is most frequently involved, but any toe may be involved. pg.1139)

A client has Paget's disease. An appropriate nursing diagnosis for this client is: a) Fatigue b) Risk for falls c) Delayed wound healing d) Risk for infection

B (Risk for falls Explanation: The client with Paget's disease is at risk for falls secondary to pathological fractures and impaired gait/mobility. pg.1147)

A patient stepped on an acorn while walking barefoot in the backyard and developed an infection progressing to osteomyelitis. What microorganism does the nurse understand is most often the cause of the development of osteomyelitis? a) Proteus b) Staphylococcus aureus c) Salmonella d) Pseudomonas

B (Staphylococcus aureus Explanation: More than 50% of bone infections are caused by Staphylococcus aureus and increasingly of the variety that is methicillin resistant (i.e., methicillin-resistant Staphylococcus aureus [MRSA]) (Miller & Kaplan, 2009). Other pathogens include the gram-positive organisms streptococci and enterococci, followed by gram-negative bacteria, including pseudomonas. pg.1148)

The nurse is caring for patient with a hip fracture. The physician orders the patient to start on a bisphosphonate. Which medication would the nurse document as given? a) Raloxifene (Evista) b) Teriparatide (Forteo) c) Denosumab (Prolia) d) Alendronate (Fosamax)

D (Alendronate (Fosamax) Explanation: Alendronate (Fosamax) is a bisphosphonate medication. Raloxifene (Evista) is a selective estrogen receptor modulator. Terparatide (Forteo) is an anabolic agent, and denosumab (Prolia) is a monoclonal antibody agent. pg.1144)

The nurse is preparing a client for a surgical procedure that will allow visualization of the extent of joint damage of the knee for a client with rheumatoid arthritis and also obtain a sample of synovial fluid. What procedure will the nurse prepare the client for? a) Arthroplasty b) Open reduction c) Needle aspiration d) Arthroscopy

D (Arthroscopy Explanation: Arthroscopic examination may be carried out to visualize the extent of joint damage as well as to obtain a sample of synovial fluid. An open reduction would be used for the treatment of a fracture. Needle aspiration will not allow visualization of the joint damage but will allow obtaining the sample of synovial fluid. Arthroplasty is the restructure of the joint surface after diagnosis is made. pg.1100)

Ms. Simpson has come to the clinic with foot pain. The physician has described her problem as a flexion deformity of the proximal interphalangeal joint. What is the name of this disorder? a) Mallet toe b) Hallux valgus (bunion) c) Heberden's nodes d) Hammer toe

D (Hammer toe Explanation: Hammer toe is a flexion deformity of the proximal interphalangeal joint. Mallet toe is a flexion deformity of the distal interphalangeal joint. Bunion is a deformity of the great toe at its metatarsophalangeal joint. Heberden's nodes are bony enlargements of the distal interphalangeal joints. This is a finding in degenerative joint disease. pg.1139)

A patient diagnosed with osteoporosis is being discharged home. Which of the following is the priority education the nurse should provide? a) Classifying medications b) Increasing calcium and vitamin D in the diet c) Participating in weight-bearing exercises d) Removing all small rugs from the home

D (Removing all small rugs from the home Explanation: A patient with osteoporosis is at risk for fractures related to falls. The home environment needs to be evaluated for safety issues, such as rugs and other objects that could cause a fall. All other education is important in educating the patient, but the risk for injury with a fall and potential for a fracture makes safety in the home environment a priority. pg.1143)

Morton's neuroma is exhibited by which of the following clinical manifestations? a) Inflammation of the foot-supporting fascia b) Longitudinal arch of the foot is diminished c) High arm and a fixed equinus deformity d) Swelling of the third (lateral) branch of the median plantar nerve

D (Swelling of the third (lateral) branch of the median plantar nerve Explanation: Morton's neuroma is swelling of the third branch of the median plantar nerve. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Flatfoot is a common disorder in which the longitudinal arch of the foot is diminished. Plantar fasciitis is an inflammation of the foot-supporting fascia. pg.1139)

When an infection is blood borne the manifestations include which of the following symptoms? a) Chills b) Bradycardia c) Hypothermia d) Hyperactivity

A (Chills Explanation: Manifestations include chills, high fever, rapid pulse, and generalized malaise. pg.1148)

A patient has been diagnosed with osteomalacia. What common symptoms does the nurse recognize that correlate with the diagnosis? a) Bone pain and tenderness b) Bone fractures and kyphosis c) Muscle weakness and spasms d) Softened and compressed vertebrae

A (Explanation: Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. As a result, the skeleton softens and weakens, causing pain, tenderness to touch, bowing of the bones, and pathologic fractures. On physical examination, skeletal deformities (spinal kyphosis and bowed legs) give patients an unusual appearance and a waddling gait. pg.1146)

Dupuytren's contracture causes flexion of which area(s)? a) Fourth and fifth fingers b) Ring finger c) Thumb d) Index and middle fingers

A (Fourth and fifth fingers Explanation: Dupuytren's contracture causes flexion of the fourth and fifth fingers, and frequently the middle finger. pg.1137)

Which of the following was formerly called a bunion? a) Hallux valgus b) Ganglion c) Morton's neuroma d) Plantar fasciitis

A (Hallux valgus Explanation: Hallux valgus (commonly called a bunion) is a deformity in which the great toe deviates laterally. Plantar fasciitis, an inflammation of the foot-supporting fascia, present as an acute onset of heel pain experienced with the first steps in the morning. Morton's neuroma is a swelling of the third (lateral) branch of the median plantar nerve. A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm compressible cystic swelling, usually on the dorsum of the wrist. pg. 1140)

Treatment of metastatic bone cancer includes which of the following? a) Palliation b) Radiation c) Combination chemotherapy and radiation d) Chemotherapy

A (Palliation Explanation: The treatment of metastatic bone cancer is palliative. The therapeutic goal is to relieve the patient's pain and discomfort while promoting quality of life. pg.1152)

A client with low back pain is being seen in the clinic. In planning care, which teaching point should the nurse include? a) Use the large muscles of the leg when lifting items. b) Avoid twisting and flexion activities. c) Sleep on the stomach to alleviate pressure on the back. d) A soft mattress is most supportive by conforming to the body.

A (Use the large muscles of the leg when lifting items. Explanation: The large muscles of the leg should be used when lifting. pg.1134)

Ans: C Feedback: Inadequate fracture immobilization can delay or prevent union. A short-term vitamin D deficiency would not likely prevent bone union. VTE is a serious complication but would not be a cause of nonunion. Similarly, bleeding would not likely delay union.

A patient has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication? A) Inadequate vitamin D intake B) Bleeding at the injury site C) Inadequate immobilization D) Venous thromboembolism (VTE)

Ans: C, D, E Feedback: Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and CRPS are later complications of fractures.

A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism

Ans: B Feedback: The nurse will encourage the patient to engage in exercises that strengthen the unaffected muscles. Comfort measures may include appropriate use of analgesics and elevation of the affected extremity to the heart level. Topical anesthetics are not typically used.

A patient with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the patient to do? A) Elevate the affected extremity to shoulder level when at rest. B) Engage in exercises that strengthen the unaffected muscles. C) Apply topical anesthetics to accessible skin surfaces as needed. D) Avoid using analgesics so that further damage is not masked.

Ans: A Feedback: When the knee is struck medially, damage may occur to the lateral collateral ligament. If the knee is struck laterally, damage may occur to the medial collateral ligament. The ACL and PCL are not typically injured in this way.

An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The patients description of the injury indicates that his knee was struck medially while his foot was on the ground. The nurse knows that the patient likely has experienced what injury? A) Lateral collateral ligament injury B) Medial collateral ligament injury C) Anterior cruciate ligament injury D) Posterior cruciate ligament injury

Ans: B Feedback: Fractures of the neck of the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may become ischemic. For this reason, AVN is common in patients with femoral neck fractures. Infections are not immediate complications and phantom pain applies to patients with amputations, not hip fractures.

An older adult patient has fallen in her home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the patients pre-surgical care, the nurse should be aware of the patients heightened risk of what complication? A) Osteomyelitis B) Avascular necrosis C) Phantom pain D) Septicemia

A client with diabetes punctured his foot with a broken acorn in the yard. Within a week, the client developed osteomyelitis of the foot. The client was admitted for IV antibiotic therapy. How long does the nurse anticipate the client will receive IV antibiotics? a) 7 to 10 days b) 3 to 6 weeks c) 6 months d) 3 months

B (3 to 6 weeks Explanation: Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for 3 to 6 weeks. Oral antibiotics then follow for as long as 3 months. pg.1148)

The client diagnosed with osteosarcoma is scheduled for a surgical amputation. Which nursing diagnosis would be a priority for this client compared with other surgical clients? a) Impaired physical mobility b) Risk for infection c) Disturbed body image d) Inadequate nutrition

C (Disturbed body image Explanation: Amputation of a body part can result in disturbances in body image. pg.1153)

Which sign may be helpful in identifying carpal tunnel syndrome? a) Brudzinski's b) Babinski's c) Tinel's d) Kernig's

C (Tinel's Explanation: Tinel's sign may be used to help identify carpal tunnel syndrome. The presence of the Babinski's sign can identify disease of the brain and spinal cord in adults and also exists as a primitive reflex in infants. The Brudzinski's and Kernig's sign are indicative of meningeal irritation. pg.1136)

The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided? a) "I will bend at the waist when I am lifting objects from the floor." b) "Instead of turning around to grasp an object, I will twist at the waist." c) "I will lie prone with my legs slightly elevated." d) "I will avoid prolonged sitting or walking."

D ("I will avoid prolonged sitting or walking." Explanation: The nurse encourages the patient to alternate lying, sitting, and walking activities frequently, and advises the patient to avoid sitting, standing, or walking for long periods. pg.1133)

A client with suspected osteomalacia has a fractured tibia and fibula. What test would give a definitive diagnosis of osteomalacia? a) Elevated levels of alkaline phosphatase b) Increased and decreased areas of bone metabolism c) Demineralization of the bone d) A bone biopsy

D (A bone biopsy Explanation: A definitive diagnosis is obtained by bone biopsy. Radiographic studies demonstrate demineralization of the bone. A bone scan detects increased and decreased areas of bone metabolism. Alkaline phosphatase levels are detected from a blood sample. pg.1146)

Which group is at the greatest risk for osteoporosis? a) Asian women b) Men c) African American women d) Caucasian women

D (Caucasian women Explanation: Small-framed, nonobese Caucasian women are at greatest risk for osteoporosis. Asian women of slight build are at risk for low peak BMD. African American women, who have a greater bone mass that Caucasian women, are less susceptible to osteoporosis. Men have a greater peak bone mass and do not experience sudden estrogen reduction. pg.1141)

Ans: B Feedback: The most serious complication of a supracondylar fracture of the humerus is Volkmanns ischemic contracture, which results from antecubital swelling or damage to the brachial artery. This complication is specific to humeral fractures.

The orthopedic nurse should assess for signs and symptoms of Volkmanns contracture if a patient has fractured which of the following bones? A) Femur B) Humerus C) Radial head D) Clavicle

A client seeks medical attention for a ganglion. Which statement about this musculoskeletal mass is true? a) Dorsiflexion exacerbates signs and symptoms of a ganglion. b) Surgical excision is the treatment of choice for a ganglion. c) A ganglion is a precursor to a primary bone tumor. d) A ganglion is the most common benign soft-tissue mass in the foot.

A (Dorsiflexion exacerbates signs and symptoms of a ganglion. Explanation: Dorsiflexion exacerbates signs and symptoms of a ganglion. A ganglion is the most common benign soft-tissue mass in the hand, not foot. It isn't a known precursor to a primary bone tumor. To treat a ganglion, the physician aspirates the ganglion, then injects a corticosteroid into the joint; the physician may also order nonsteroidal anti-inflammatory agents. Surgical excision is necessary only if signs and symptoms persist and the client's range of motion is impaired. pg.1137)

Which of the following is a flexion deformity caused by a slowly progressive contracture of the palmar fascia? a) Dupuytren's contracture b) Callus c) Hallux valgus d) Hammertoe

A (Dupuytren's contracture Explanation: Dupuytren's disease results in a slowly progressive contracture of the palmar fascia, called Dupuytren's contracture. A callus is a discretely thickened area of skin that has been exposed to persistent pressure or friction. A hammertoe is a flexion deformity of the interphangeal joint, which may involve several toes. Hallux valgus is a deformity in which the great toe deviates laterally. pg.1137)

Which is a flexion deformity caused by a slowly progressive contracture of the palmar fascia? a) Dupuytren's contracture b) Callus c) Hammertoe d) Hallux valgus

A (Explanation: Dupuytren's disease results in a slowly progressive contracture of the palmar fascia, called Dupuytren's contracture. A callus is a discretely thickened area of skin that has been exposed to persistent pressure or friction. A hammertoe is a flexion deformity of the interphalangeal joint, which may involve several toes. Hallux valgus is a deformity in which the great toe deviates laterally. pg.1137)

Ans: C Feedback: Amputations present a serious threat to any patients body image. None of the other listed diagnoses is specifically associated with amputation.

A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patients postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care? A) Ineffective Thermoregulation B) Risk-Prone Health Behavior C) Disturbed Body Image D) Deficient Diversion Activity

Ans: A, B, C, E Feedback: Health promotion measures after an older adults hip fracture include weight-bearing exercise, promotion of a healthy diet, falls prevention, and bone density testing. Corticosteroids have the potential to reduce bone density and increase the risk for fractures.

A nurse is planning the care of an older adult patient who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage which of the following? Select all that apply. A) Regular bone density testing B) A high-calcium diet C) Use of falls prevention precautions D) Use of corticosteroids as ordered E) Weight-bearing exercise

Assessment of a client reveals signs and symptoms of Paget's disease. Which of the following would be most likely? a) Skull narrowing b) Long bone bowing c) Lordosis d) Waddling gait

B (Explanation: Some clients with Paget's disease are asymptomatic with only some mild skeletal deformity. Other clients have marked skeletal deformities which may include enlargement of the skull, bowing of the long bones, and kyphosis. Waddling gait is associated with osteomalacia. pg.1146)

During a routine physical examination of a client, the nurse observes a flexion deformity of the promixal interphalangeal (PIP) joint of two toes on the right foot. The nurse documents this finding as which of the following? a) Mallet toe b) Hammer toe c) Bunion d) Hallux valgus

B (Hammer toe Explanation: Hammer toe is a flexion deformity of the proximal interphalangeal (PIP) joint and may involve several toes. Mallet toe is a flexion deformity of the distal interphalangeal joint (DIP), and also can affect several toes. Hallux valgus, also called a bunion, is a deformity of the great (large) toe at its metatarsophalangeal joint. pg.1139)

A client with Paget's disease comes to the hospital and complains of difficulty urinating. The emergency department physician consults urology. What should the nurse suspect is the most likely cause of the client's urination problem? a) Urinary tract infection (UTI) b) Renal calculi c) Benign prostatic hyperplasia d) Dehydration

B (Renal calculi Explanation: Renal calculi commonly occur with Paget's disease, causing pain and difficulty when urinating. A UTI commonly causes fever, urgency, burning, and hesitation with urination. Benign prostatic hyperplasia is common in men older than age 50; however, because the client has Paget's disease, the nurse should suspect renal calculi, not benign prostatic hyperplasia. Dehydration causes a decrease in urine production, not a problem with urination. pg.1142)

When describing malignant bone tumors to a group of students, which of the following would the instructor cite as the usual location? a) Wrist-hand junction b) Femur-hip area c) Distal femur around the knee d) Proximal humerus

C (Distal femur around the knee Explanation: Malignant bone tumors usually are located around the knee in the distal femur or proximal fibula; a few are found in the proximal humerus. The wrist-hand junction and femur-hip area are not common sites. pg.1151)

The nurse recognizes that goal of treatment for metastatic bone cancer is to: a) Promote pain relief and quality of life b) Cure the diseased bone and cartilage c) Diagnose the extent of bone damage d) Reconstruct the bone with a prosthesis

A (Promote pain relief and quality of life Explanation: Treatment of metastatic bone cancer is palliative. pg.1152)

Which of the following presents with an onset of heel pain with the first steps of the morning? a) Morton's neuroma b) Hallux valgus c) Plantar fasciitis d) Ganglion

C (Plantar fasciitis Explanation: Plantar fasciitis, an inflammation of the foot-supporting fascia, present as an acute onset of heal pain experienced with the first steps in the morning. Hallux valgus (commonly called a bunion) is a deformity in which the great toe deviates laterally. Morton's neuroma is a swelling of the third (lateral) branch of the median plantar nerve. A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm compressible cystic swelling, usually on the dorsum of the wrist. pg.1139)

A nurse is caring for a client who's experiencing septic arthritis. This client has a history of immunosuppressive therapy and his immune system is currently depressed. Which assignment is the most appropriate for the nurse caring for this client? a) The nurse caring for this client is also caring for four clients receiving chemotherapy for cancer treatment on the oncology floor. b) The nurse caring for this client is also caring for two other immunosuppressed clients on the medical intensive care unit. c) The nurse is caring for this client on the intensive care unit. d) The nurse caring for this client is also caring for four other immunosuppressed clients on the medical floor.

C (The nurse is caring for this client on the intensive care unit. Explanation: This client is critically ill; his diagnosis and immunosuppression place him at a high risk for infection. The most appropriate place for this client is in an intensive care unit, where the nurse can focus exclusively on his health promotion. This client shouldn't be on the oncology floor. This client requires close monitoring. The nurse caring for this client shouldn't also be caring for other clients who may require frequent interventions. pg.1151)

A 70-year-old client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis, which objective is most appropriate? a) Maintaining vitamin levels b) Maintaining protein levels c) Promoting range-of-motion (ROM) exercises d) Promoting weight-bearing exercises

D (Promoting weight-bearing exercises Explanation: When the mechanical stressors of weight bearing are absent, disuse osteoporosis can occur. Therefore, if the client does weight-bearing exercises, disuse complications can be prevented. Maintaining protein and vitamins levels is important, but neither will prevent osteoporosis. ROM exercises will help prevent muscle atrophy and contractures. pg.1141)

On a visit to the family physician, a client is diagnosed with a bunion on the lateral side of the great toe, at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session? a) "Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." b) "Bunions are congenital and can't be prevented." c) "Bunions are caused by a metabolic condition called gout." d) "Bunions may result from wearing shoes that are too big, causing friction when the shoes slip back and forth."

A ("Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." Explanation: Bunions may be congenital or may be acquired by wearing shoes that are too short or narrow, which increases pressure on the bursa at the metatarsophalangeal joint. Acquired bunions can be prevented. Wearing shoes that are too big may cause other types of foot trauma but not bunions. Gout doesn't cause bunions. Although a client with gout may have pain in the big toe, such pain doesn't result from a bunion. pg.1140)

Ms. Malcolm has come to your clinic complaining of jaw pain. This is also associated with muscle spasm and tenderness of the masseter and temporalis muscles. The physician has diagnosed a temporomandibular disorder (TMD). What would the treatment course for this client include? Select all that apply. a) Referral to a dentist who has experience managing clients with TMD b) Analgesics c) Custom-fitted mouth guard during sleep d) Corticosteroids

A (Referral to a dentist who has experience managing clients with TMD b) Analgesics c) Custom-fitted mouth guard during sleep Explanation: Referral to a dentist who has experience managing clients with TMD, analgesics, and custom-fitted mouth guard during sleep are all part of the treatment course. Corticosteroids are not part of the treatment regimen. pg.1241)

A nurse is performing discharge teaching for an elderly client with osteoporosis. Which instruction about taking a calcium supplement should the nurse include? a) Take the supplement with meals or with orange juice. b) Take the supplement on an empty stomach with a full glass of water. c) Remain in an upright position 30 minutes after taking the supplement. d) Take weekly on the same day and at the same time.

A (Take the supplement with meals or with orange juice. Explanation: Calcium supplements, such as Caltrate or Citracal, are over-the-counter medications. They should be taken with meals or with a beverage high in vitamin C. pg.1144)

A client has been treated for migraine headaches for several months and comes to the clinic stating he is getting no better. The nurse is talking with the client and hears an audible click when the client is moving his jaw. What does the nurse suspect may be happening? a) Temporomandibular disorder b) Trigeminal neuralgia c) Loose teeth d) Dislocated jaw

A (Temporomandibular disorder Explanation: The disorder can be confused with trigeminal neuralgia and migraine headaches. The client experiences clicking of the jaw when moving the joint, or the jaw can lock, which interferes with opening the mouth. Loose teeth will not cause a clicking of the jaw. The client does not have a dislocated jaw. pg.1236)

The nurse is educating a patient with lower back pain on proper lifting techniques. The nurse would document what behavior as evidence the education was effective? a) The patient placed the load close to the body. b) The patient reached over head with arms fully extended. c) The patient used a narrow base of support. d) The patient bent at the hips and tightened the abdominal muscles.

A (The patient placed the load close to the body. Explanation: Instructions for the patient with low back pain should include that when lifting, the patient should avoid overreaching. The patient should also keep the load close to the body, bend the knees and tighten the abdominal muscles, use a wide base of support, and use a back brace to protect the back. Bending at the hips increases the strain on the back muscles when lifting. pg.1134)

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following actions? a) Walk or perform weight-bearing exercises b) Decrease the intake of vitamin A and D c) Reduce stress d) Increase fiber in the diet

A (Walk or perform weight-bearing exercises Explanation: Risk-lowering strategies for osteoporosis include walking or exercising outdoors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation. pg.1144)

Ans: A Feedback: Intra-articular fractures often lead to post-traumatic arthritis. Research does not indicate a correlation between intra-articular fractures and FES, osteomyelitis, or compartment syndrome.

A 25-year-old man is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this patient. What sequela of intra-articular fractures should the nurse describe regarding this patient? A) Post-traumatic arthritis B) Fat embolism syndrome (FES) C) Osteomyelitis D) Compartment syndrome

Ans: A Feedback: The nurse encourages the patient to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early, because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for patients with BKAs. The nurse also discourages sitting for prolonged periods of time.

A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals? A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in a chair for at least 8 hours a day

Ans: C Feedback: Fat embolism syndrome occurs most frequently in young adults and elderly patients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement.

A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome

Ans: D Feedback: Treatment of a sprain consists of resting and elevating the affected part, applying cold, and using a compression bandage. After the acute inflammatory stage (usually 24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises would likely be painful.

A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following? A) Apply heat for the first 24 to 48 hours after the injury. B) Maintain the ankle in a dependent position. C) Exercise hourly by performing rotation exercises of the ankle. D) Keep an elastic compression bandage on the ankle.

Ans: A Feedback: The patient has a significant risk for osteomyelitis and tetanus due to the fact that the fracture is open. Powerlessness and ineffective role performance are psychosocial diagnoses that may or may not apply, and which would be superseded by immediate physiologic threats such as infection. Surgical positioning injury is not plausible, since surgery is not likely indicated.

A nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a patient with an open fracture of the radius? A) Risk for Infection B) Risk for Ineffective Role Performance C) Risk for Perioperative Positioning Injury D) Risk for Powerlessness

Ans: A Feedback: The nurse should apply a tourniquet in the event of postsurgical hemorrhage. Elevating the limb and applying sterile gauze are likely insufficient to stop the hemorrhage. The nurse should attempt to control the immediate bleeding before contacting the surgeon.

A patient has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurses initial postsurgical assessment were unremarkable but the patient has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurses initial action? A) Apply a tourniquet B) Elevate the residual limb. C) Apply sterile gauze. D) Call the surgeon.

Ans: B Feedback: The nurse should include monitoring for sufficient blood supply by assessing the color, temperature, and pulses of the affected extremity. Weight-bearing exercises are encouraged, but passive ROM exercises have the potential to cause pain and inhibit healing. Corticosteroids, vitamin D, and calcium are not normally administered.

A patient has sustained a long bone fracture and the nurse is preparing the patients care plan. Which of the following should the nurse include in the care plan? A) Administer vitamin D and calcium supplements as ordered. B) Monitor temperature and pulses of the affected extremity. C) Perform passive range of motion exercises as tolerated. D) Administer corticosteroids as ordered.

Ans: C Feedback: The patient is encouraged to exercise as much as possible by means of the overbed trapeze. This device helps strengthen the arms and shoulders in preparation for protected ambulation. Independent logrolling may result in injury due to the location of the fracture. Leg lifts would be contraindicated for the same reason. Massage by the nurse is not a substitute for exercise.

A patient is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of immobility. What intervention best addresses the patients need for exercise? A) Performing gentle leg lifts with both legs B) Performing massage to stimulate circulation C) Encouraging frequent use of the overbed trapeze D) Encouraging the patient to log roll side to side once per hour

Ans: A Feedback: A patient should be able to use assistive devices appropriately and safely prior to discharge. Scar formation will not be complete at the time of hospital discharge. It is anticipated that the patient will require some assistance with ADLs postdischarge. Pain should be well managed, but may or may not be wholly absent.

A patient who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge? A) Patient can demonstrate safe use of assistive devices. B) Patient has a healed, non-tender, non-adherent scar C) Patient can perform activities of daily living independently D) Patient is free of pain

Ans: A Feedback: Amputation of an extremity affects the patients ability to provide adequate self-care. The patient is encouraged to be an active participant in self-care. The patient and the nurse need to maintain positive attitudes and to minimize fatigue and frustration during the learning process. Balanced nutrition and the patients learning style are important variables in the rehabilitation process but the patients attitude is among the most salient variables. The patients presurgical level of function may or may not affect participation in rehabilitation.

A rehabilitation nurse is working with a patient who has had a below-the-knee amputation. The nurse knows the importance of the patients active participation in self-care. In order to determine the patients ability to be an active participant in self-care, the nurse should prioritize assessment of what variable? A) The patients attitude B) The patients learning style C) The patients nutritional status D) The patients presurgical level of function

Ans: B Feedback: Patients who have experienced sports-related injuries are often highly motivated to return to their previous level of activity. Adherence to restriction of activities and gradual resumption of activities needs to be reinforced. Appropriate analgesia use must be encouraged, but analgesia does not necessarily have to be taken in the absence of pain. If healing is complete, the patient does not likely have a greatly increased risk of reinjury. Dislocations rarely cause bleeding after the healing process.

An elite high school football player has been diagnosed with a shoulder dislocation. The patient has been treated and is eager to resume his role on his team, stating that he is not experiencing pain. What should the nurse emphasize during health education? A) The need to take analgesia regardless of the short-term absence of pain B) The importance of adhering to the prescribed treatment and rehabilitation regimen C) The fact that he has a permanently increased risk of future shoulder dislocations D) The importance of monitoring for intracapsular bleeding once he resumes playing

Ans: D Feedback: If a dislocation or subluxation is not reduced immediately, avascular necrosis (AVN) may develop. Bone remodeling does not take place because a fracture has not occurred. Realignment does not become more difficult with time and pain would subside with time, not become worse.

An emergency department patient is diagnosed with a hip dislocation. The patients family is relieved that the patient has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurses statement? A) The longer the joint is displaced, the more difficult it is to get it back in place. B) The patients pain will increase until the joint is realigned. C) Dislocation can become permanent if the process of bone remodeling begins. D) Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved.

During a routine physical examination on a 75-year-old female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse? a) "After age 40, height may show a gradual decrease as a result of spinal compression" b) "After menopause, the body's bone density declines, resulting in a gradual loss of height." c) "The posture begins to stoop after middle age." d) "There may be some slight discrepancy between the measuring tools used."

B ("After menopause, the body's bone density declines, resulting in a gradual loss of height." Explanation: The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question. pg.1143)

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure? a) Instructing the client to ambulate twice daily b) Administering large doses of I.V. antibiotics as ordered c) Withholding all oral intake d) Administering large doses of oral antibiotics as ordered

B (Administering large doses of I.V. antibiotics as ordered Explanation: Treatment of acute osteomyelitis includes large doses of I.V. antibiotics (after blood cultures identify the infecting organism). Surgical drainage may be indicated, and the affected bone is immobilized. The client usually requires I.V. fluids to maintain hydration, but oral intake isn't necessarily prohibited. pg.1148)

The nurse notes that the patient's left great toe deviates laterally. This finding would be recognized as which of the following? a) Hammertoe b) Hallux valgus c) Pes cavus d) Flatfoot

B (Hallux valgus Explanation: Hallux valgus is commonly referred to as a bunion. Hammertoes are usually pulled upward. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot. pg.1140)

Which is a deformity in which the great toe deviates laterally? a) Hammertoe b) Hallux valgus c) Pes cavus d) Plantar fasciitis

B (Hallux valgus Explanation: Hallux valgus is a deformity in which the great toe deviates laterally. A hammertoe is a flexion deformity of the interphalangeal joint, which may involve several toes. Pes cavus refers to a foot with an abnormally high arch and a fixed equines deformity of the forefoot. Plantar fasciitis is an inflammation of the foot-supporting fascia. pg.1140)

Which of the following should be included in the teaching plan for a patient diagnosed with plantar fasciitis? a) The pain of plantar fasciitis diminishes with warm water soaks. b) Management of plantar fasciitis includes stretching exercises. c) Plantar fasciitis presents as an acute onset of pain localized to the ball of the foot that occurs when pressure is placed upon it and diminishes when pressure is released. d) Complications of plantar fasciitis include neuromuscular damage and decreased ankle range of motion.

B (Management of plantar fasciitis includes stretching exercises. Explanation: Management also includes wearing shoes with support and cushioning to relieve pain, orthotic devices (eg, heel cups, arch supports), and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Plantar fasciitis, an inflammation of the foot-supporting fascia, presents as an acute onset of heel pain experienced with taking the first steps in the morning. The pain is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon. Unresolved plantar fasciitis may progress to fascial tears at the heel and eventual development of heel spurs. pg.1139)

A patient is having low back pain. What position can the nurse suggest to relieve this discomfort? a) Prone, with a pillow under the shoulders b) Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees c) High-Fowler's to allow for maximum hip flexion d) Supine, with the bed flat and a firm mattress in place

B (Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees Explanation: A medium to firm, nonsagging mattress (a bed board may be used) is recommended; there is no evidence to support the use of a firm mattress (National Guideline Clearinghouse, 2010). Lumbar flexion is increased by elevating the head and thorax 30 degrees by using pillows or a foam wedge and slightly flexing the knees supported on a pillow. Alternatively, the patient can assume a lateral position with knees and hips flexed (curled position) with a pillow between the knees and legs and a pillow supporting the head (Fig. 42-1). A prone position should be avoided because it accentuates lordosis. pg.1134)

A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct? a) Obtaining the recommended daily allowance of calcium requires taking a calcium supplement. b) The recommended daily allowance of calcium may be found in a wide variety of foods. c) Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. d) To prevent fractures, the client should avoid strenuous exercise

B (The recommended daily allowance of calcium may be found in a wide variety of foods. Explanation: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary. pg.1143)

A physician diagnoses primary osteoporosis in a client who has lost bone mass. In this metabolic disorder, the rate of bone resorption accelerates while bone formation slows. Primary osteoporosis is most common in: a) young menstruating women. b) elderly postmenopausal women. c) young children. d) elderly men.

B (elderly postmenopausal women. Explanation: Although the cause of primary osteoporosis is unknown, an important contributing factor may be faulty protein metabolism resulting from estrogen deficiency and a sedentary lifestyle. Typically, these conditions occur in elderly postmenopausal women. pg.1143)

A patient is diagnosed with osteogenic sarcoma. What laboratory studies should the nurse monitor for the presence of elevation? a) Potassium level b) Magnesium level c) Alkaline phosphatase d) Troponin levels

C (Alkaline phosphatase Explanation: Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma or bone metastasis. Hypercalcemia is also present with bone metastases from breast, lung, or kidney cancer. Symptoms of hypercalcemia include muscle weakness, fatigue, anorexia, nausea, vomiting, polyuria, cardiac dysrhythmias, seizures, and coma. Hypercalcemia must be identified and treated promptly. pg.1152)

A nurse is caring for an elderly female client with osteoporosis. When teaching the client, the nurse should include information about which major complication? a) Negative calcium balance b) Dowager's hump c) Bone fracture d) Loss of estrogen

C (Bone fracture Explanation: Bone fracture is a major complication of osteoporosis; it results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause — not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance isn't a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature. pg.1144)

Which medication directly inhibits osteoclasts thereby reducing bone loss and increasing BMD? a) Teriparatide (Forteo) b) Vitamin D c) Calcitonin (Miacalcin) d) Raloxifene (Evista)

C (Calcitonin (Miacalcin) Explanation: Miacalcin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD. Evista reduces the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. Forteo has been recently approved by the FDA for the treatment of osteoporosis. pg.1143)

A patient comes to the clinic complaining of low back pain radiating down the left leg. After diagnostic studies rule out any pathology, the physician orders a serotonin-norepinephrine reuptake inhibitor (SNRI). Which medication does the nurse anticipate educating the patient about? a) Cyclobenzaprine (Flexeril) b) Amitriptyline (Elavil) c) Duloxetine (Cymbalta) d) Gabapentin (Neurontin)

C (Duloxetine (Cymbalta) Explanation: Nonprescription analgesics such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) and short-term prescription muscle relaxants (e.g., cyclobenzaprine [Flexeril]) are effective in relieving acute low back pain. Tricyclic antidepressants (e.g., amitriptyline [Elavil) and the newer dual-action serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine [Cymbalta]) (Karp et al., 2010) or atypical seizure medications (e.g., gabapentin [Neurontin], which is prescribed for pain from radiculopathy) are used effectively in chronic low back pain. pg.1133)

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following actions? a) Decrease the intake of vitamin A and D b) Reduce stress c) Walk or perform weight-bearing exercises outdoors d) Increase fiber in the diet

C (Walk or perform weight-bearing exercises outdoors Explanation: Risk-lowering strategies for osteoporosis include walking or exercising outdoors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation. pg.1145)

Ans: A Feedback: Syme amputation (modified ankle disarticulation amputation) is performed most frequently for extensive foot trauma and produces a painless, durable extremity end that can withstand full weight-bearing. Therefore, each of the other teaching statements is incorrect.

The patient scheduled for a Syme amputation is concerned about the ability to eventually stand on the amputated extremity. How should the nurse best respond to the patients concern? A) You will eventually be able to withstand full weight-bearing after the amputation. B) You will have minimal weight-bearing on this extremity but youll be taught how to use an assistive device. C) You likely will not be able to use this extremity but you will receive teaching on use of a wheelchair. D) You will be fitted for a prosthesis which may or may not allow you to walk.

Which of the following terms refers to disease of a nerve root? a) Radiculopathy b) Contracture c) Involucrum d) Sequestrum

A (Radiculopathy Explanation: When the patient reports radiating pain down the leg, he or she is describing radiculopathy. Involucrum refers to new bone growth around the sequestrum. Sequestrum refers to dead bone in an abscess cavity. Contracture refers to abnormal shortening of muscle or fibrosis of joint structures. pg.1133)

Ans: C Feedback: Open fractures are graded according to the following criteria. Grade I is a clean wound less than 1 cm long. Grade II is a larger wound without extensive soft-tissue damage. Grade III is highly contaminated, has extensive soft-tissue damage, and is the most severe. There is no grade IV fracture.

A 20 year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is highly contaminated and there is extensive soft-tissue damage. How would this patients fracture likely be graded? A) Grade I B) Grade II C) Grade III D) Grade IV

Ans: D Feedback: A patient with a clavicle fracture may use a sling to support the arm and relieve the pain. The patient may be permitted to use the arm for light activities within the range of comfort. The patient should not elevate the arm above the shoulder level until the ends of the bones have united, but the nurse should encourage the patient to exercise the elbow, wrist, and fingers.

A nurse is preparing to discharge an emergency department patient who has been fitted with a sling to support her arm after a clavicle fracture. What should the nurse instruct the patient to do? A) Elevate the arm above the shoulder 3 to 4 times daily. B) Avoid moving the elbow, wrist, and fingers until bone remodeling is complete. C) Engage in active range of motion using the affected arm. D) Use the arm for light activities within the range of motion.

Ans: A Feedback: Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure. Ordering different analgesics does not address the underlying problem. Encouraging the patient to move the fingers or perform range-of-motion exercises will not treat or prevent compartment syndrome. Petaling the edges of a cast with tape prevents abrasions and skin breakdown, not compartment syndrome.

A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A) Prepare the patient for opening or bivalving of the cast. B) Obtain an order for a different analgesic. C) Encourage the patient to wiggle and move the fingers. D) Petal the edges of the patients cast.

Ans: D Feedback: The multidisciplinary rehabilitation team helps the patient achieve the highest possible level of function and participation in life activities. The team is not primarily motivated by efficiency, the need for holistic care, or the need to foster the patients body image, despite the fact that each of these are valid goals.

A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A) Maximize the efficiency of care B) Ensure that the patients health care is holistic C) Facilitate the patients adjustment to a new body image D) Promote the patients highest possible level of function

A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include? a) "This condition is associated with various sports." b) "Ergonomic changes can be incorporated into your workday to reduce stress on your wrist." c) "Surgery is the only sure way to manage this condition." d) "Using arm splints will prevent hyperflexion of the wrist."

B ("Ergonomic changes can be incorporated into your workday to reduce stress on your wrist." Explanation: Ergonomic changes, such as adjusting keyboard height, can help clients with carpal tunnel syndrome avoid hyperextension of the wrist. This condition is associated with repetitive tasks such as clerical work, not sports. The condition may be managed with medications, yoga, acupuncture, and wrist (not arm) splints. pg.1136)

A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include? a) "Most falls among the elderly occur outside the home. Clients should confine themselves to their homes as much as practical." b) "Because of the increase in home burglaries involving the elderly, these clients should have burglar bars on every window in the home." c) "Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars." d) "Most accidental injuries among the elderly are automobile-related. Elderly clients should have vision testing every 6 months while they're still driving."

C ("Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars." Explanation: Falls in the home cause most injuries among the elderly. Elderly clients should take measures to decrease the clutter that can contribute to falls, such as removing objects such as throw rugs from the floor. Elderly clients should also install grab bars in the shower and next to the toilet. The threat of fire makes burglar bars on every window impractical. pg.1144)

Which of the following would the nurse use to determine that a client is exhibiting signs and symptoms of chronic osteomyelitis? a) Rapid pulse b) Tenderness over the affected area c) Persistent draining sinus d) High fever

C (Persistent draining sinus Explanation: Persistent draining sinus indicates a chronic infection in a client with osteomyelitis. High fever, rapid pulse, and tenderness or pain over the affected area is evidence of an acute infection. pg.1148)

A patient had hand surgery to correct a Dupuytren's contracture. What nursing intervention is a priority postoperatively? a) Applying a cock-up splint and immobilization b) Changing the dressing c) Having the patient exercise the fingers to avoid future contractures d) Performing hourly neurovascular assessments for the first 24 hours

D (Performing hourly neurovascular assessments for the first 24 hours Explanation: Hourly neurovascular assessment of the exposed fingers for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion. pg.1137)