Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders

7. A patient with a casted, fractured left leg asks why the leg has to be elevated. What should the nurse respond to this patient? a. Decreases swelling. b. Prevents cast cracking. c. Increases your comfort. d. Allows the cast to dry evenly.

ANS: A A casted limb is elevated for 24 to 48 hours, and ice can be applied above and below the cast to reduce swelling. B. C. D. The limb is not elevated to prevent cast cracking, promote comfort, or to allow the cast to dry evenly.

10. The nurse is reinforcing teaching provided to a patient with rheumatoid arthritis (RA). Which patient statement indicates understanding of the symptoms of RA? a. Fatigue b. Paralysis c. Crepitation d. Shortness of breath

ANS: A Because of the systemic nature of RA, in addition to pain and joint involvement, the patient may have a low-grade fever, malaise, depression, lymphadenopathy, weakness, fatigue, anorexia, and weight loss. B. C. D. Paralysis, crepitation, and shortness of breath are not manifestations of RA.

21. A patient who has a displaced mid-shaft fracture of the left femur and is in balanced suspension skeletal traction with 35 pounds of weights is experiencing calf pain with right foot dorsiflexion. Which action should the nurse take? a. Notify the RN. b. Check the traction setup. c. Reduce 5 pounds of weight. d. Encourage dorsiflexion more frequently.

ANS: A Calf pain on dorsiflexion can indicate a thrombophlebitis (Homans sign). The RN should be informed. B. The nurse should not take the time now to check the traction setup. C. Traction weight cannot be reduced without a physicians order. D. The patient should not be encouraged to exercise the limb now since a thrombophlebitis might be present.

4. The nurse finds a 2-day postoperative patient who had a right total hip replacement lying supine with crossed legs. What data should the nurse collect on this patient? a. The right leg for shortening b. The right knee for crepitation c. The left leg for internal rotation d. The left leg for loss of function

ANS: A Crossing the legs puts the hip at risk for dislocation. Symptoms are pain in the affected hip, shortening of the leg, and possibly rotation of the surgical leg. B. The patient did not have surgery on the right knee. C. D. The patient did not have surgery to the left limb.

27. The nurse is reinforcing teaching provided to a patient who is postmenopausal, has lost 2 inches of height, and has osteoporosis. Which patient statement indicates correct understanding of the purpose of calcium supplements? a. To decrease bone loss b. To increase energy levels c. To decrease serum calcium d. To increase excretion of calcium

ANS: A If serum calcium falls below normal levels, the parathyroid glands stimulate the bone to release calcium into the bloodstream. The result is demineralized bone. Therefore, calcium supplements are used. B. C. D. Calcium is not taken to increase energy levels, decrease serum calcium, or to increase the excretion of calcium.

18. The nurse is reinforcing teaching for a patient who has had a total hip replacement on correct sitting positions. Which position should the nurse teach the patient to avoid? a. Crossing legs b. Elevating legs c. Flexing ankles d. Extending knees

ANS: A Legs should be kept abducted (away from center of body), so legs should not be crossed. B. C. D. These positions do not need to be avoided for the patient with a total hip replacement.

28. A patient is completing instructions about complications that can occur from osteoporosis. Which complication should the patient state as evidence that teaching has been effective? a. Hip fracture. b. Overgrowth of bone. c. Bone spur formation. d. Increased bone density.

ANS: A Osteoporotic bone may cause a pathological fracture in which the hip breaks before the fall. For other patients, a fall can cause a hip or other fracture. B. C. D. Bone overgrowth, spurs, or increases in bone density are not complications of osteoporosis.

22. The nurse is contributing to the plan of care for a patient who is scheduled for a below-the-knee amputation. What nursing diagnosis should be recommended for the preoperative plan of care? a. Anxiety b. Self-Care Deficit c. Fluid Volume Deficit d. Ineffective Airway Clearance

ANS: A Patients facing surgery and especially a body image changing surgery such as amputation will experience anxiety. Interventions to aid with this anxiety should be planned. B. C. D. These would be appropriate after surgery has occurred.

6. The nurse is reinforcing teaching provided to a patient recovering from right total hip replacement. Which patient statement indicates a correct understanding of the teaching? a. Keep legs apart. b. Lie prone in bed. c. Move right leg closer to the left leg. d. Do not bear any weight on the left leg.

ANS: A Prevention of dislocation is a major nursing responsibility. Correct positioning of the surgical leg is critical. The primary goals are to prevent hip adduction which is done by keeping the legs apart. B. C. D. These actions will not prevent hip adduction.

26. The nurse is caring for a patient with gout. Which laboratory value should the nurse review which indicates that the treatment plan is effective? a. Uric acid: 7.9 mg/dL b. Creatinine: 0.8 mg/dL c. Blood urea nitrogen: 15 mg/dL d. Low-density lipoprotein (LDL): 115 mg/dL

ANS: A The diagnosis of gout is based on an elevated serum uric acid level which is a waste product resulting from the breakdown of proteins. Urate crystals, formed because of excessive uric acid buildup, are deposited in joints and other connective tissues, causing severe inflammation. B. C. D. Creatinine, blood urea nitrogen, and lipoprotein levels are not used in the diagnosis or treatment of gout.

31. The nurse checks a patients casted right leg resting upon a pillow and finds that the cast appears too tight. What should the nurse do? a. Notify the RN. b. Administer pain medication. c. Apply an extra blanket to the leg. d. Remove the pillow under the cast.

ANS: A The nurse should notify the RN. A serious complication of a cast being too tight is compartment syndrome. The physician needs to be contacted for orders to cut the cast with a cast cutter to relieve pressure and prevent pressure necrosis of the underlying skin. B. There is no information to support that the patient is in pain. C. There is no information to support that the limb is cool. D. The limb should be elevated or supported with pillows.

39. The nurse is caring for a patient in traction. Which actions are appropriate when caring for this patient? (Select all that apply.) a. Allow weights to hang freely in place. b. Use assistance to reposition the patient in bed. c. Hold weights up if the patient is shifting position in bed. d. Remove weights if the patient is being moved up in bed. e. Lighten weights for short periods if the patient reports pain.

ANS: A, B Weights are to hang unobstructed. Assistance should be used to pull the patient up in bed to protect the health care worker from injury. C. D. E. Weights should never touch the floor or be removed or lifted.

42. The nurse is caring for a patient with a minor rotator cuff shoulder injury. What should the nurse emphasize when reviewing care with this patient? (Select all that apply.) a. Apply ice b. Rest the shoulder c. Take NSAIDs as prescribed d. Begin out-patient physical therapy e. Use 2 lb hand weights for exercising

ANS: A, B, C, D For minor rotator cuff injury, resting the shoulder, ice, NSAIDs, and physical therapy are recommended. E. The use of hand weights will be determined by the physical therapist.

36. A patient 48 hours after surgery for a fractured femoral shaft is experiencing mental confusion, tachycardia, tachypnea, and dyspnea. The patients blood pressure is elevated and petechiae are present on the chest. After reporting the findings to the RN what should the nurse do while awaiting the physicians specific orders? (Select all that apply.) a. Administer oxygen. b. Prepare patient for arterial blood gas tests. c. Prepare patient for chest x-ray or lung scan. d. Maintain bedrest and keep movement to a minimum. e. Ask patient to move affected limb to see if pain is worse. f. Place patient in high Fowlers position or raise the head of the bed.

ANS: A, B, C, D, F The patient is likely experiencing a fat emboli. The patient should be placed in a high Fowlers position to aid breathing, diagnostic tests will be done, and the patient is kept on bedrest to reduce oxygenation needs and clot movement. Oxygen may be started per agency policy to aid in respiration. E. Limb should not be moved to prevent further release of fat

41. A patient in the ambulatory clinic is diagnosed with a muscle strain. What actions should the nurse instruct the patient to do to treat this injury? (Select all that apply.) a. Rest the limb. b. Elevate the limb. c. Apply heat for 1 hour. d. Apply ice to the area. e. Wrap with an elastic bandage.

ANS: A, B, D, E RICE is an acronym for rest, ice, compression, and elevation which is the therapy for strain injuries. Immediately after a strain, the injured area should be rested to protect it. Ice should be applied to decrease pain, swelling, and inflammation. Applying an elastic bandage for compression and elevating the affected area provide support and minimize swelling. C. After inflammation subsides, heat application (15 to 30 minutes four times a day) brings increased blood flow to the injured area for healing. Heat should not be immediately applied for 1 hour.

38. The nurse is collecting data from a patient suspected of developing a fat embolus from a fracture of the right femur. Which manifestations should the nurse expect? (Select all that apply.) a. Petechiae b. A migraine c. Tachycardia d. Mental confusion e. Numbness in the right leg f. Muscle spasms in the right thigh

ANS: A, C, D The earliest manifestation of fat emboli syndrome (FES) is altered mental status from a low arterial oxygen level. The patient then experiences tachycardia, tachypnea, fever, high blood pressure, severe respiratory distress, and petechiae. B. E. F. These are not manifestations of fat emboli.

40. The nurse is contributing to the plan of care for a patient recovering from total hip replacement. Which exercises should the nurse recommend to help prevent deep vein thrombosis (DVT) formation? (Select all that apply.) a. Foot circles b. Toe touches c. Heel pumping d. Deep knee bends e. Quadriceps setting f. Straight leg raises (SLRs)

ANS: A, C, E, F Because most DVTs occur in the lower extremities, leg exercises are started in the immediate postoperative period and include heel pumping, foot circles, and SLRs. The patient also performs quadriceps-setting exercises (quad sets). B. D. Deep knee bends and toe touches are not standard postoperative exercises and would be restricted in a patient with a total hip replacement due to restricted hip flexion.

37. A patient asks the difference between osteoarthritis and rheumatoid arthritis. What manifestations should the nurse explain are characteristic of rheumatoid arthritis? (Select all that apply.) a. Low-grade fever b. Heberdens nodes c. Autoimmune disease d. Activity increases pain e. Early morning stiffness f. Involvement of other major organs

ANS: A, C, E, F Rheumatoid arthritis is a systemic autoimmune disease with morning stiffness, low-grade fever, and organ involvement. B. Heberdens nodes are seen in osteoarthritis. D. Pain increases with activity in osteoarthritis.

8. The nurse is caring for a patient who has had a right hip replacement. For which position is the nurse attempting to achieve when a pillow is placed between the legs during turning? a. Flexion of the knees b. Abduction of the thighs c. Adduction of the hip joint d. Hyperextension of the knees

ANS: B A trapezoid-shaped abduction pillow (sometimes called a triangular pillow), splint, wedge, or regular bed pillows may be used between the legs to maintain abduction and prevent adduction. Some research, however, indicates that these precautions may not be necessary and may slow recovery. A. D. The pillow is not used to support knee flexion or hyperextension. C. Adduction of the hip joint is to be prevented.

13. A patient with gout has been instructed on the prescribed medication allopurinol (Zyloprim). Which patient statement indicates understanding of the action of this medication? a. Excretes proteins. b. Blocks formation of uric acid. c. Increases formation of purines. d. Increases metabolism of purines.

ANS: B Allopurinol decreases uric acid production. A. C. D. Allopurinol (Zyloprim) does not excrete proteins or increase the formation or metabolism of purines.

30. The nurse reinforces medication teaching provided to a patient with rheumatoid arthritis. Which medication should the patient identify as helpful to control the symptoms of the health problem? a. Digoxin. b. Ibuprofen. c. Morphine. d. Penicillin.

ANS: B Ibuprofen (an NSAID) blocks activity of the enzyme cyclooxygenase, which makes prostaglandins that produce inflammation, fever, and pain found in rheumatoid arthritis. A. Digoxin is a cardiac medication. C. Morphine is an opioid which may not help reduce inflammation. D. Penicillin is an antibiotic, used to treat bacterial infections.

1. The nurse is contributing to the plan of care for a patient who has a right fractured femur. What intervention should the nurse include in the plan of care to prevent fat emboli? a. Decrease dietary consumption of fats. b. Maintain immobilization of the right leg. c. Encourage coughing and deep breathing hourly. d. Perform passive range of motion on the right leg.

ANS: B Prevention of fat emboli includes keeping the fracture immobilized and hydrating the patient to help dilute and excrete any fat that may escape from the fractured bone. A. Decreasing the consumption of fat will not help prevent fat emboli. C. D. Deep breathing and coughing and performing passive range of motion will not prevent the development of fat emboli.

2. A patient has an open reduction of a radial fracture and is casted. Several hours after the operation, the patient reports a throbbing pain in the arm. What nursing action is essential for the nurse to take? a. Reposition arm. b. Perform neurovascular checks. c. Administer analgesics as ordered. d. Notify the physician immediately.

ANS: B The nurse should begin with data collection to determine what the next action to take. For this patient the nurse should perform neurovascular checks. A. The arm might need to be positioned however this should not be done until a neurovascular check is completed. C. Administering pain medication might be indicted however should not be done until a pain assessment is completed. D. The nurse needs to determine the patients neurovascular status before notifying the physician.

44. The nurse is assisting in the development of an educational seminar on prevention of osteoporosis for a group of community members. Which actions should the nurse suggest be included in this presentation? (Select all that apply.) a. Drink one cup of caffeinated coffee each day b. Ensure an adequate intake of calcium each day c. Participate in weight-bearing exercise every day d. Wear well-supporting nonskid shoes at all times e. Consider participating in resistance exercise training

ANS: B, C, D, E Actions to prevent the development of osteoporosis include ensuring an adequate intake of calcium each day, participating in weight-bearing exercise such as walking each day, wearing well-supporting, nonskid shoes at all times, and participating in resistance exercise such as weight training. A. Caffeine is a modifiable risk factor for the development of osteoporosis.

12. The nurse is caring for a patient who has a newly casted, fractured wrist. Data collection reveals slightly puffy fingers with good capillary refill. What should the nurse do now to prevent complications? a. Notify the RN. b. Apply heat to the cast. c. Elevate the cast on pillows. d. Remove the pillow under the cast.

ANS: C A casted limb is elevated for 24 to 48 hours, and ice can be applied above and below the cast to reduce swelling. A. The RN does not need to be notified. B. Heat should not be applied at this time. D. The pillow should not be removed from under the cast.

29. The nurse is reviewing data collected during the health history for a patient with osteoporosis. What should the nurse identify as a risk factor for osteoporosis development? a. Daily use of antacid b. Walking 1 mile daily c. Increased caffeine intake d. Increased dairy food intake

ANS: C A risk factor for osteoporosis is excessive caffeine intake or alcohol. A. B. D. Antacids, walking, and dairy intake are not risk factors for the development of osteoporosis.

34. An 87-year-old female with a history of osteoarthritis reports an average generalized pain score of 4 on a 0-to-10 scale while using acetaminophen prn. Which response about this pain level should the nurse make to the patient? a. Do you take a daily calcium supplement? b. Im glad the acetaminophen is working for you. c. Are you satisfied with this level of pain control? d. Research shows that acetaminophen is not really effective for osteoarthritis pain.

ANS: C Acetaminophen can be helpful in reducing pain associated with osteoarthritis, so the nurse should assess whether the patient is satisfied with the current level of pain control. A. Calcium supplementation is not related to pain control. B. D. These statements miss the opportunity to assess whether the patient is both comfortable and functional with the current pain management.

17. The nurse is contributing to the plan of care for a patient who has a fractured hip and is placed in Bucks (boot) traction while awaiting surgery. What is the desired outcome for placing the patient in Bucks traction? a. Restrain patient. b. Realign fracture. c. Relieve patient pain. d. Maintain fracture reduction.

ANS: C Bucks traction does not promote bone alignment or healing but is used instead for relief of painful muscle spasms that often accompany fractures. A. Traction is not used to restrain a patient.

11. A patient with a 36-hour-old fractured femur is in traction and is prescribed morphine 10 mg every 3 hours as needed. The patient received a dose 3 hours ago and is now reporting a pain level of 8. The patient is stable. Which action should the nurse take? a. Hold medication. b. Notify the registered nurse (RN). c. Give pain medication as ordered. d. Give pain medication in 30 minutes.

ANS: C The data collection findings are normal. Since it is time for the pain medication and the patient is in pain, the medication can be given. A. B. D. There is no need to hold the medication, notify the RN, or wait to give the medication in 30 minutes.

20. The nurse observes a petechial rash and respiratory distress in a patient recovering from a fractured femur. What should these findings suggest to the nurse? a. Infection b. Pneumonia c. Fat embolism d. Pleural effusion

ANS: C The earliest manifestation of fat embolism syndrome is altered mental status from a low arterial oxygen level. The patient then experiences tachycardia, tachypnea, fever, high blood pressure, severe respiratory distress, and petechiae. A. B. D. These findings are not manifestations of infection, pneumonia, or pleural effusion.

23. The nurse is reinforcing teaching on positioning for a patient after a right total knee replacement. Which patient statement indicates a correct understanding of the teaching? a. Prone. b. Side lying. c. Supine with pillow under right knee. d. Supine with three pillows between legs.

ANS: C The patient lies supine with pillow under right knee if a continuous passive motion (CPM) machine is not used after a total knee replacement. A. B. D. The patient recovering from a total knee replacement does not need to be placed in the prone, side lying, or supine position with pillows between the legs.

15. The nurse is reinforcing teaching provided to a patient with gout. Which food should the patient state will be avoided that indicates teaching has been effective? a. Rice b. Beets c. Liver d. Bananas

ANS: C The patient should be instructed to avoid high-purine (protein) foods such as organ meats, shellfish, and oily fish. A. B. D. Rice, beets, and bananas do not need to be avoided.

24. The nurse is reinforcing teaching provided to a patient for carpal tunnel syndrome treatment. Which patient statement indicates a correct understanding of the teaching? a. Bedrest. b. Arm sling. c. Wrist splint. d. Hand exercises.

ANS: C The wrist is rested to reduce inflammation, and a wrist splint may be prescribed to do this. A. B. D. Bedrest, an arm sling, and hand exercises are not indicated for treatment of this syndrome.

19. The nurse is contributing to the plan of care for a patient who has an upper extremity amputation. Why should the nurse keep in mind that this type of amputation can be more debilitating than a lower extremity amputation when planning care? a. The upper extremity is more visible. b. Prosthetic fitting is easier for the leg. c. The upper extremity is more specialized. d. There is greater blood supply to the upper extremity.

ANS: C Upper extremity amputations are usually more significant than lower extremity amputations as the arms and hands are necessary for performing activities of daily living. A. B. D. Upper extremity amputations are not more debilitating because the upper extremity is more visible, the prosthetic fitting is easier for the leg, or because of a greater blood supply to the upper extremities.

43. During a health history the nurse becomes concerned that a patient is at risk for developing osteoporosis. Which modifiable risk factors did the nurse use to come to this conclusion? (Select all that apply.) a. Small boned b. Postmenopausal c. Cigarette smoking d. Sedentary lifestyle e. Low calcium intake

ANS: C, D, E Modifiable risk factors for the development of osteoporosis include cigarette smoking, sedentary lifestyle, and low calcium intake. A. B. Bone structure and menopausal status are non-modifiable risk factors for the health problem.

32. The nurse is contributing to the plan of care for a patient who has a bone fracture that is splintered and has shattered into numerous fragments. Which term should the nurse use to document this type of fracture? a. Impacted b. Avulsion c. Greenstick d. Comminuted

ANS: D A bone splintered or shattered into numerous fragments is a comminuted fracture that often occurs in crushing injuries. A. Impacted describes a bone that is forcibly pushed together, resulting in bone being pushed into bone. B. Avulsion describes a piece of bone that is torn away from the main bone while still attached to a ligament or tendon. C. Greenstick describes a bone that is bent and fractures on the outer arc of the bend.

9. The nurse sees a neighbor fall and fracture a leg. What should the nurse do first for the neighbor? a. Assess pain. b. Transport to an emergency department. c. Cover site of open fracture with clean dressing. d. Immobilize the affected limb using minimal movement.

ANS: D For emergency care of a suspected fracture, do not try to reposition the limb. Splint it as it lies and ensure that the limb is secured above and below the break to minimize movement and bone grating. A. B. C. Then cover site, transport, and assess pain level.

35. A patient is diagnosed with osteomyelitis of the right lower leg. What should the nurse expect to be prescribed for this patients care? a. Anticoagulant therapy b. Casting of the extremity c. Fasciotomy of the wound d. Long-term antibiotic therapy

ANS: D Long-term antibiotic therapy (4-6 weeks) is the treatment of choice for patients with osteomyelitis. A. Anticoagulant therapy is prescribed for a thromboembolism. B. Casting is indicated for a fracture. C. Fasciotomy may be indicated to treat compartment syndrome.

16. The nurse is contributing to the plan of care for a patient with Pagets disease. Which outcome should the nurse identify as being appropriate for this patient? a. Gain 5 lb weekly. b. Intake equals output. c. Identify coping skills. d. Pain is relieved at a satisfactory level.

ANS: D Pain control is a major issue with many patients with Pagets disease. The outcome stating that pain is relieved at a satisfactory level is the most appropriate for this patient. A. B. C. Outcomes that address weight gain, intake and output, and coping skills are not necessarily appropriate for this patient.

3. The nurse is monitoring a patient with a casted left tibial fracture and a contusion of the thigh. The patient reports increasing pain in the left foot that has not been relieved by morphine injections. What should the nurse do? a. Reposition the casted leg. b. Repeat the morphine injection now. c. Give a higher ordered dose of morphine. d. Ensure physician is immediately notified.

ANS: D The early symptom of acute compartment syndrome is the patients report of severe, increasing pain that is not relieved with narcotics, so the physician should be notified. A. B. C. These actions might be done if prescribed by the physician.

25. A patient with a fractured pelvis and a left acetabular fracture is prescribed bedrest. When the patient asks to toilet, which measure would be appropriate? a. Help patient up on a commode very carefully. b. Turn patient onto right side, place the bedpan behind, and turn back. c. Have patient sit up as high as possible and lift self up with hands pushing on the bed, then slide the bedpan underneath. d. Ask patient to lift straight up using a trapeze mounted above the bed and slide a bedpan underneath from the right side.

ANS: D The nurse should ask the patient to lift straight up using a trapeze mounted above the bed and slide a bedpan underneath from the right side to avoid the left fracture. A. The patient is on bedrest so a bedside commode is not appropriate. B. The patient should not be turned. C. The patient should be instructed to use the trapeze and not attempt to push self up using the bed.

5. The nurse is caring for a patient who had a closed reduction of the ulna with a cast applied. Later the patient reports left arm pain. What should the nurse do first? a. Pad the edges of the cast. b. Notify the physician immediately. c. Administer an analgesic as ordered. d. Perform neurovascular check on fingers.

ANS: D The nurse should begin with data collection to determine what the next action is to take. The nurse should perform a neurovascular check. A. The edges of the cast may need to be padded if this is the cause of the patients pain. B. The physician should not be notified until neurovascular checks are performed. C. The nurse needs to assess the patients pain level before providing an analgesic.

14. The nurse is evaluating teaching provided to a patient with gout. Which patient menu selection indicates that additional teaching is required? a. Pike b. Bass c. Perch d. Sardines

ANS: D The patient should avoid high-purine (protein) foods, such as organ meats, shellfish, and oily fish (e.g., sardines). A. B. C. These food items would be appropriate for the patient being treated for gout.

33. The nurse reinforces teaching on prevention of osteomyelitis with a patient who has an open fracture of the right leg. Which patient statement indicates that teaching has been effective? a. Apply ice to right leg. b. Keep leg immobilized. c. Increase calcium intake in diet. d. Wash hands prior to touching fracture area.

ANS: D Washing hands prior to touching a fracture area is the best way to help prevent osteomyelitis. C. Calcium is related to osteoporosis prevention. B. Keeping the leg immobilized relates to fat emboli reduction. A. Ice is applied to reduce swelling.