Chapter 63 Musculoskeletal problems
In which order should the nurse implement interventions prescribed for a patient admitted with acute osteomyelitis who has a temperature of 101.2° F? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain blood cultures from two sites. b. Administer dose of gentamicin 60 mg IV. c. Send to radiology for computed tomography (CT) scan of right leg. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever.
A, B, D, C
Which actions should the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur? (Select all that apply.) A. Monitor serum calcium. B. Teach about the need for strict bed rest. C. Explain the use of sustained-release opioids. D. Support the left leg when repositioning the patient. E. Assist family and patient as they discuss the prognosis.
A, C, D, E. The nurse will monitor for hypercalcemia caused by bone decalcification. Support of the leg helps reduce the risk for pathologic fractures. Although the patient may be reluctant to exercise, activity is important to maintain function and avoid complications associated with immobility. Adequate pain medication, including sustained-release and rapid-acting opioids, is needed for the severe pain often associated with bone cancer. The prognosis for metastatic bone cancer is poor, so the patient and family need to be supported as they deal with the reality of the situation.
Which persons are at high risk for chronic low back pain? (SATA) A. A 63-year-old man who is long-distance truck driver B. A 30-year-old nurse who works on an orthopedic unit and smokes C. A 55-year-old construction worker who is 6ft, 2in and weighs 250lb D. A 44-year-old female chef with prior compression fracture of the spine. E. A 28-year-old female yoga instructor who is 5ft, 6in and weighs 130 lb.
A,B,C,D Causes of chronic low back pain include (1) degenerative conditions, such as arthritis or disc disease; (2) osteoporosis; (3) weakness from the scar tissue of prior injury; and (4) chronic strain on lower back muscles from obesity, pregnancy, or jobs that require repetitive heavy lifting, vibration, and prolonged sitting. Health care personnel are at high risk for low back pain. Lifting and moving patients, excessive time being stooped over or leaning forward, and frequent twisting can cause low back pain.
A patient who has had surgical correction of bilateral hallux valgus is being discharged from the same-day surgery unit. The nurse will teach the patient to A. rest frequently with the feet elevated B. wear shoes continually except when bathing C. soak feet in warm water several times a day D. expect the feet to be numb for the next few days
A. After surgical correction of bilateral hallux valgus, the feet should be elevated with the heel of the bed to reduce discomfort and decrease edema.
The nurse is admitting a patient with a history of a herniated lumbar disc and low back pain. Which action would likely aggravate the pain? A. Bending or lifting B. Application of warm moist heat C. Sleeping in a side-lying position D. Sitting in a fully extended recliner
A. Back pain related to a herniated lumbar disc is aggravated by events and activities that increase stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc.
The nurse is caring for a patient hospitalized with a herniated lumbar disc and an exacerbation of chronic bronchitis. Which breakfast choice would be most appropriate for the patient to select from the breakfast menu? A. Bran muffin B. Scrambled eggs C. Puffed rice cereal D. Buttered white toast
A. Each meal should contain one or more sources of fiber to reduce the risk of constipation and straining with defecation, which increases back pain. A patient with chronic breathing difficulties also will benefit from regularity and ease of bowel evacuation. In addition, if lumbar nerve compression is present, bowel and bladder function may be impaired. Bran is a typical high-fiber food choice and is an appropriate selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber.
Which action should the nurse take when caring for a patient with osteomalacia? A. Teach about the use of vitamin D supplements. B. Educate about the need for weight-bearing exercise. C. Instruct the patient to avoid dairy products in the diet. D. Discuss the use of medications such as bisphosphonates.
A. Osteomalacia is caused by inadequate intake or absorption of vitamin D. Weight-bearing exercise and bisphosphonate administration may be used for osteoporosis but will not be beneficial for osteomalacia. Because ultraviolet light is needed for the body to synthesize vitamin D, the patient might be taught that 20 minutes a day of sun exposure is beneficial.
A patient with acute osteomyelitis asks the nurse how this problem will be treated initially. Which response by the nurse is most appropriate? A. "IV antibiotics are usually required for several weeks." B. "Oral antibiotics are often required for several months." C. "Surgery is almost always necessary to remove the dead tissue that present." D. "Drainage of the foot and instilling antibiotics into the affected area are the usual therapy."
A. The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. However, as many as 3 to 6 months may be required. Bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all microorganisms. Surgery may be used for chronic osteomyelitis, to include debridement of the devitalized, infected tissue and irrigation of the affected bone with antibiotics.
A patient with osteomyelitis undergoes surgical debridement with implantation of antibiotic bead. When the patient asks why the beads are used, the nurse answers (SATA) A. "oral or IV antibiotcs are not effective in most cases of bone infection." B. "the beads are an adjunct to debridement and antibiotics for deep infection." C. " the beads are used to deliver antibiotics directly to the site of the infection." D. "this is the safest method to deliver longe-term antibiotic therpay for bone infection." E. "ischemia and bone death related to osteomyelitis are impenetrable to IV antibiotics."
B,C. Treatment of chronic osteomyelitis includes surgical removal of the poorly perfused tissue and dead bone in addition to the extended use of IV and oral antibiotics. Antibiotic acrylic bead chains may be placed during surgery to help fight the infection.
During a health screening event, which assessment finding in a 61-yr-old patient would alert the nurse to the possible presence of osteoporosis? A. Presence of bowed legs B. Measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation
B. A gradual but measurable loss of height and the development of kyphosis ("dowager's hump") are indicative of the presence of osteoporosis. Bowed legs may be caused by abnormal bone development or rickets but are not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative of its presence. A wide gait is used to support balance and does not indicate osteoporosis.
A patient with osteosarcoma of the humerus shows understanding of his treatment options when he states A. "I accept that I have to lose my are with surgery." B. "the chemotherapy before surgery will shrink the tumor." C. "This tumor is related to the melanoma I had 3 years ago." D. "I am glad they can take out the cancer with such a small scar."
B. A patient with osteosarcoma usually has preoperative chemotherapy to decrease tumor size. This increases the chance that limb-salvage procedures, including wide surgical resection of the tumor, can be done. Osteosarcoma is an extremely aggressive primary bone tumor that rapidly metastasizes to distant sites.
The nurse provides instructions to a 30-yr-old office worker who has low back pain. Which statement indicate additional patient teaching is required? A. "Switching between hot and cold packs may relieve pain and stiffness." B. "Acupuncture to the lower back would cause irreparable nerve damage." C. "Smoking may aggravate back pain by decreasing blood flow to the spine." D. "Sleeping on my side with knees and hips bent reduces stress on my back."
B. Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic purposes.
In caring for a patient after spinal fusion, the nurse would report which finding to the health care provider? A. the patient has a single episode of emesis B. The patient is unable to move lower extremities C. the patient is nauseated and has not voided in 4 hours D. the patient reports of pain at the bone graft donor site
B. After spinal fusion surgery, the nurse should frequently monitor peripheral neurovascular condition. Movement of the arms and legs and assessment of sensation should be no worse in comparison with the preoperative status. These assessments are repeated at least every 2 to 4 hours during the first 48 hours after surgery, and findings are compared with the preoperative assessment. The nurse should immediately report any new muscle weakness to the HCP and record this in the patient's medical record.
A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action should the nurse include in the plan of care? A. Logroll the patient every 2 hours. B. Assist the patient with ambulation. C. Discuss the need for genetic testing with the patient. D. Teach the patient about the muscle biopsy procedure.
B. Because the goal for the patient with muscular dystrophy is to keep the patient active for as long as possible, assisting the patient to ambulate will be part of the care plan. The patient will not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but are not necessary for a patient who already has a diagnosis. There is no need for genetic testing because the patient already knows the diagnosis.
A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first? A. Patient who reports foot pain after hammertoe surgery. B. Patient who has not voided 8 hours after a laminectomy. C. Patient with low back pain and a positive straight-leg-raise test. D. Patient with osteomyelitis who has a temperature of 100.5° F (38.1°
B. Difficulty in voiding may indicate damage to the spinal nerves and should be assessed and reported to the surgeon immediately. The information about the other patients is consistent with their diagnoses. The nurse will need to assess them as quickly as possible, but the information about them does not indicate a need for immediate intervention.
A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective? A. "I will keep my back straight when I lift above than my waist." B. "I will begin doing exercises to strengthen and support my back." C. "I will tell my boss I need a job where I can stay seated at a desk." D. "I can sleep with my hips and knees extended to prevent back strain."
B. Exercises can help strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back than keeping these joints extended. Sitting for prolonged periods can aggravate back pain. Modification in the way the patient lifts boxes is needed, but the patient should not lift above the level of the elbows.
A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention should the nurse include in the initial plan of care? A. Quadriceps-setting exercises B. Immobilization of the left leg C. Positioning the left leg in flexion D. Assisted weight-bearing ambulation
B. Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fracture. Weight-bearing exercise increases the risk for pathologic fractures. Flexion of the affected limb is avoided to prevent contractures.
The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. When completing a focused assessment, which symptom should the nurse expect? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg
B. Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized rather than generalized throughout the leg.
Which assessment finding for a 55-yr-old patient should alert the nurse to the presence of osteoporosis? A. Bowed legs B. Loss of height C. Report of frequent falls D. Aversion to dairy products
B. Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia and osteoarthritis. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis.
what is the most important to include in the teaching plan for a patient with osteopenia? A. lose weight B. Stop smoking C. Eat a high-protein diet D. start swimming for exercise
B. Patients with osteopenia should be taught to quit smoking to decrease bone loss. Pathologic fractures can result from low-energy trauma in areas with abnormally weak bone. This is typically seen in osteoporosis but can also occur in areas with metastatic or primary bone tumors. L.R. was unaware that her breast cancer had recurred. The first manifestation of her cancer recurrence was when she fractured her femur in a fall.
Which nursing intervention is most appropriate when turning a patient after spinal surgery? A. Having the patient turn to the side by grasping the side rails to help turn B. Placing a pillow between the patient's legs and turning the body as a unit C. Elevating the head of bed 30 degrees and having the patient extend the legs while turning D. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed
B. Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort after spinal surgery. The other interventions will not maintain proper spine alignment and may cause spinal damage.
Which action should the nurse take first when a patient is seen in the outpatient clinic with neck pain? A. Provide information about therapeutic neck exercises. B. Ask about numbness or tingling of the hands and arms. C. Suggest the patient alternate the use of heat and cold to the neck. D. Teach about the use of nonsteroidal antiinflammatory drugs (NSAIDs).
B. The nurse's initial action should be further assessment of related symptoms because cervical nerve root compression will require different treatment than musculoskeletal neck pain. The other actions may also be appropriate, depending on the assessment findings.
A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information should the nurse include in the discharge teaching? A. How to apply warm packs to the leg to reduce pain B. How to monitor and care for a long-term IV catheter C. The need for daily aerobic exercise to help maintain muscle strength D. The reason for taking oral antibiotics for 7 to 10 days after discharge
B. The patient will be taking IV antibiotics for several months. The patient will need to recognize signs of infection at the IV site and know how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.
The nurse is planning health promotion teaching for a 45-yr-old patient with asthma who has low back pain from herniated lumbar disc. What activity would the nurse include in an individualized exercise plan for the patient? A. Yoga B. Walking C. Calisthenics D. Weightlifting
B. The patient would benefit from an aerobic exercise that considers the patient's health status and fits the patient's lifestyle. The best exercise is walking, which builds strength in the back and leg muscles without putting undue pressure or strain on the spine. If the patient has exercise-induced asthma, the nurse would recommend use of a rescue inhaler prior to exercise. Yoga, calisthenics, and weightlifting would all put pressure on or strain the spine.
Which action should the nurse take when repositioning the patient who has just had a laminectomy and discectomy? A. Instruct the patient to move the legs before turning the rest of the body. B. Place a pillow between the patient's legs and turn the entire body as a unit. C. Have the patient turn by grasping the side rails and pulling the shoulders over. D. Turn the patient's head and shoulders first, followed by the hips, legs, and feet.
B. The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.
What action should the nurse complete before administering alendronate (Fosamax) to a patient with osteoporosis? A. Ask about any leg cramps or hot flashes. B. Assist the patient to sit up at the bedside. C. Be sure that the patient has recently eaten. D. Administer the ordered calcium carbonate.
B. To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates.
A patient who has low back pain from a herniated lumbar disc is having muscle spasms. Which nursing intervention would be most appropriate? A. Provide gentle ROM to the lower extremities. B. Elevate the head of the bed 20 degrees and flex the knees. C. Place a small pillow under the patient's upper back to gently flex the lumbar spine. D. Place the bed in reverse Trendelenburg with the patient's feet against the footboard.
B. To reduce pain, the nurse should elevate the head of the bed 20 degrees and have the patient flex the knees to avoid extension of the spine. The slight flexion provided by this position often is comfortable for a patient with a herniated lumbar disc. ROM to the lower extremities will be limited to prevent extremes of spinal movement. Reverse Trendelenburg and a pillow under the patient's upper back will more likely increase pain.
Which information should the nurse include when teaching a patient with acute low back pain? (Select all that apply.) A. Sleep in a prone position with the legs extended. B. Keep the knees straight when leaning forward to pick something up. C. Expect symptoms of acute low back pain to improve in a few weeks. D. Avoid activities that require twisting of the back or prolonged sitting. E. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.
C, D, E. Acute back pain usually starts to improve within 2 weeks. In the meantime, the patient should use medications such as nonsteroidal antiinflammatory drugs (NSAIDs) or acetaminophen to manage pain and avoid activities that stress the back. Sleeping in a prone position and keeping the knees straight when leaning forward will place stress on the back and should be avoided.
The nurse receives report from the licensed practical nurse (LPN/VN) about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement? A. "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus." B. "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed." C. "The patient who had spinal surgery 3 hours ago is reporting a headache and has clear drainage on the dressing." D. "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management."
C. After spinal surgery, there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery, patients often wear a soft or hard cervical collar to immobilize the neck.
A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. Which statement by the patient should indicate to the nurse the need for additional teaching related to health maintenance? A. "I'm frustrated with this endless treatment!" B. "I will take my oral temperature twice a day." C. "I think my left foot is starting to droop down." D. "I use crutches to avoid weight bearing on the left leg."
C. Footdrop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis.
The nurse is admitting a patient who reports the new onset of lower back pain. To distinguish between the pain of a lumbar herniated disc from other causes, what is the best question for the nurse to ask the patient? A. "Is the pain worse in the morning or in the evening?" B. "Is the pain sharp and stabbing or burning and aching?" C. "Does the pain radiate down the buttock or into the leg?" D. "Is the pain totally relieved by acetaminophen (Tylenol)?"
C. Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve. It is often described as traveling through the buttock to the posterior thigh or down the leg. This is because the herniated disc causes compression on spinal nerves as they exit the spinal column. Time of occurrence, type of pain, and pain relief questions do not elicit differentiating data.
The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which patient statement indicates to the nurse that additional teaching is needed? A. "I will need to participate in physical therapy after surgery." B. "I wish I did not need to have chemotherapy after this surgery." C. "I did not have this bone cancer until my leg broke a week ago." D. "I can use the patient-controlled analgesia (PCA) to manage postoperative pain."
C. Osteogenic sarcoma may be diagnosed following a fracture, but it is not caused by the injury. The other statements indicate patient teaching has been effective.
The nurse is caring for patients in a primary care clinic. Which patient is most at risk to develop osteomyelitis caused by Staphylococcus aureus? A. A 22-yr-old female patient with gonorrhea who is an IV drug user B. A 48-yr-old male patient with muscular dystrophy and acute bronchitis C. A 32-yr-old male patient with type 1 diabetes and stage 4 pressure injury D. A 68-yr-old female patient with hypertension who had a knee arthroplasty 3 years ago
C. Osteomyelitis caused by S. aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices from joint arthroplasty. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.
An older adult is diagnosed with Paget's disease. Which finding would indicate improvement in the condition? A. Waddling gait B. Curvature in affected bones C. Lower serum alkaline phosphatase D. Uptake of radiolabeled bisphosphonate in affected bones
C. Paget's disease is characterized by excessive bone resorption and replacement of normal marrow with vascular, fibrous connective tissue. A normalizing alkaline phosphatase indicates bone resorption has slowed or stopped. Additional characteristics of the disease include bone pain, a waddling gait, loss of stature, and curved bones. Uptake of radiolabeled bisphosphonate indicates a bone is affected.
A 24-yr-old male patient has come to the clinic with a gradual onset of pain and swelling in the left knee. The patient is diagnosed with osteosarcoma without metastasis. Chemotherapy is ordered before surgery. How would the nurse explain the reason for preoperative chemotherapy? A. "The chemotherapy is being used to save your left leg." B. "Chemotherapy will increase your 5-year survival rate." C. "Chemotherapy is being used to decrease the tumor size." D. "Chemotherapy will help decrease the pain before and after surgery."
C. Preoperative chemotherapy is used to decrease the tumor size before surgery. The chemotherapy will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct chemotherapy after amputation or limb salvage has increased 5-year survival rates in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery.
Which action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)? A. Check ability to plantar and dorsiflex the foot. B. Determine the patient's readiness to ambulate. C. Log roll the patient from side to side every 2 hours. D. Ask about pain management with the patient-controlled analgesia (PCA).
C. Repositioning a patient is included in the education and scope of practice of UAP, and experienced UAP will be familiar with how to maintain alignment in the postoperative patient. Evaluation of the effectiveness of pain medications, assessment of neurologic function, and evaluation of a patient's readiness to ambulate after surgery require higher level nursing education and scope of practice.
What should the nurse include in the teaching plan for ae patient who has acute low back pain and muscle spasms? A. Keep both feet flat on the floor when prolonged standing is required. B. Twist gently from side to side to maintain range of motion in the spine. C. Keep the head elevated slightly and flex the knees when resting in bed. D. Avoid the use of cold packs because they will exacerbate the muscle spasms.
C. Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. Prolonged standing will cause strain on the lumbar spine, even with both feet flat on the floor. Alternate application of cold and heat should be used to decrease pain.
The nurse determines dietary teaching for a 75-yr-old patient with osteoporosis has been successful when the patient selects which meal as highest in calcium? A. Chicken stir fry with 1 cup each onions and green peas, and 1 cup of steamed rice B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple C. Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk D. A 2-egg omelet with 2 oz of American cheese, 1 slice of whole wheat toast, and a half grapefruit
C. The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium but not as much as the sardines, yogurt, and milk.
The nurse has reviewed proper body mechanics with a patient who has a history of low back pain caused by a herniated lumbar disc. Which patient statement indicates a need for further teaching? A. "I should sleep on my side or back with my hips and knees bent." B. "I should exercise at least 15 minutes every morning and evening." C. "I should pick up items by leaning forward without bending my knees." D. "I should try to keep one foot on a stool whenever I have to stand for a period of time."
C. The patient should avoid leaning forward without bending the knees. Bending the knees helps to prevent lower back strain and is part of proper body mechanics for lifting. Sleeping on the side or back with hips and knees bent and standing with a foot on a stool will decrease lower back strain. Back strengthening exercises are done twice a day once symptoms subside.
After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. What action should the nurse take? A. Elevate the right leg on two pillows. B. Obtain vital signs for indication of hemorrhage. C. Review the preoperative assessment data in the health record. D. Turn the patient to the left to relieve pressure on the right leg.
C. The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient or elevating the leg will not relieve the numbness.
A patient has had surgical reduction of an open fracture of the right radius. Which assessment findings should the nurse report immediately to the health care provider? A. Serous wound drainage B. Right arm muscle spasms C. Pain with right arm movement D. Temperature 101.4° F (38.6° C)
D. An elevated temperature suggests possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.
What should the nurse assess to evaluate the effectiveness of alendronate (Fosamax) therapy for a patient with Paget's disease? A. Oral intake B. Daily weight C. Grip strength D. Pain intensity
D. Bone pain is a common early manifestation of Paget's disease, and the nurse should assess the pain intensity to determine if treatment is effective. The other information will be collected by the nurse but will not be used in evaluating the effectiveness of the therapy.
A 58-yr-old woman with breast cancer is admitted for severe back pain related to a vertebral compression fracture. The patient's laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms would the nurse expect the patient to exhibit? A. Anxiety, irregular pulse, and weakness B. Muscle stiffness, dysphagia, and dyspnea C. Hyperactive reflexes, tremors, and seizures D. Nausea, vomiting, and altered mental status
D. Breast cancer can metastasize to the bone, with vertebrae as a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium results as calcium is released from damaged bones. Normal serum calcium is 8.6 to 10.2 mg/dL. Manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include muscle stiffness, dysphagia, and dyspnea.
Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis? A. Ask the patient about any nausea. B. Obtain the patient's oral temperature. C. Change the prescribed wet-to-dry dressings. D. Review the patient's serum creatinine results.
D. Gentamicin is nephrotoxic and can cause renal failure as reflected in the patient's serum creatinine. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.
A patient with suspected disc herniation has acute pain and muscle spasms. The nurse's responsibility is to A. Encourage total bed rest for several days B. teach principles of back strengthening exercises C. stress the importance of straight-leg raises to decrease pain D. promote use of cold and hot compression and pain medication
D. If acute pain and muscle spasms are not severe, the patient may be treated as an outpatient with NSAIDs and muscle relaxants (e.g., cyclobenzaprine). Massage and back manipulation, acupuncture, and application of cold and hot compresses may help some patients. A brief period (1 to 2 days) of rest at home may be needed for some people; most patients do better if they continue their regular activities. Prolonged bed rest should be avoided. All patients should refrain from activities that worsen the pain, including lifting, bending, twisting, and prolonged sitting.
A 54-yr-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia. Which information should the nurse explain to the patient? A. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. B. Estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. C. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. D. Calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.
D. Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy is no longer routinely given to prevent osteoporosis because of increased risk of heart disease as well as breast and uterine cancer. Corticosteroid therapy increases the risk for osteoporosis.
Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? A. Pancakes with syrup and bacon B. Whole wheat toast and fresh fruit C. Egg-white omelet and a half grapefruit D. Oatmeal with skim milk and fruit yogurt
D. Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods.
Which statement by a patient with discomfort from a bunion indicates to the nurse that more teaching is needed? A. "I will give away my high-heeled shoes." B. "I can take ibuprofen (Motrin) if I need it." C. "I will use the bunion pad to cushion the area." D. "I can only wear sandals, no closed-toe shoes."
D. The patient can wear shoes that have a wide forefoot (toe box). The other patient statements indicate the teaching has been effective.
A 67-yr-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges and elevation of the affected foot on 2 pillows. The nurse would place the highest priority on which intervention? A. Ambulate the patient to the bathroom every 2 hours. B. Ask the patient about preferred activities to relieve boredom. C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. D. Perform frequent position changes and range-of-motion exercises.
D. The patient is at risk for atelectasis of the lungs and contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest. Dangling the legs every 2 to 4 hours may be too painful.
The nurse is reinforcing health teaching about osteoporosis with a 72-yr-old patient admitted to the hospital. What should the nurse explain to the patient? A. With a family history of osteoporosis, you cannot prevent or slow bone resorption. B. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. C. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.
D. The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer.
When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching plan? A. Use prolonged bed rest to decrease fatigue. B. Continuous positive airway pressure will facilitate sleeping. C. An orthotic jacket will limit mobility and may contribute to deformity. D. Remain active to prevent skin breakdown and respiratory complications.
D. With muscular dystrophy, the patient must remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP) may be used as respiratory function decreases before mechanical ventilation is needed to sustain respiratory function.
The HCP diagnoses a patient with a plantar wart. What should the nurse know about this kind of abnormality? a. Painful papillomatous growth on the sole of the foot b. Thickening of skin on the weight-bearing part of the foot c. Local thickening of skin caused by pressure on bony prominences d. Tumor on nerve tissue between the third and fourth metatarsal heads
a. A plantar wart is a painful papillomatous growth on the sole of the foot. Thickened skin on the weight-bearing part of the foot is a callus. Local thickening of skin caused by pressure on bony prominences is a corn. A tumor on nerve tissue between the third and fourth metatarsal heads is a Morton's neuroma.
What should the nurse teach the patient recovering from an episode of acute low back pain? a. Perform daily exercise as a lifelong routine. b. Sit in a chair with the hips higher than the knees. c. Avoid occupations in which the use of the body is required. d. Sleep on the abdomen or on the back with the legs extended.
a. Proper daily stretching and strengthening exercises are an important part of the prevention of back injury, with the goal of maintaining mobility and strength in the back. Patients should sit with the knees level with the hips and should sleep in a side- lying position, with knees and hips bent, or on the back, with a device to flex the hips and knees. Good body mechanics with proper transfer and turning techniques are necessary in all jobs and activities.
A patient is started on alendronate (Fosamax) once weekly for the treatment of osteoporosis. Which patient statement indicates that further instruction about the drug is needed? a. "I should take the drug with a meal to prevent stomach irritation. "b. "This drug will prevent further bone loss and increase my bone density." c. "I need to sit or stand upright for at least 30 minutes after taking the drug." d. "I will still need to take my calcium supplements while taking this new drug."
a. The bisphosphonates, such as alendronate, must be taken with a full glass of water at least 30 minutes before food or other medications to promote their absorption. Because they are very irritating to the stomach and esophagus, the patient must remain upright for at least 30 minutes after taking these medications to prevent reflux into the esophagus. Although these drugs will prevent further bone loss and increase bone density, calcium and vitamin D supplementation is still needed for bone formation.
Identify ways to prevent osteoporosis in postmenopausal women (select all that apply). a. Eating more beef b. Eating 8 ounces of yogurt daily c. Performing weight-bearing exercised. d. Spending 15 minutes in the sun each day e. Taking postmenopausal estrogen replacement
b, c. Increased calcium and vitamin D intake and weight-bearing exercises (i.e., walking) are the best methods to prevent osteoporosis in postmenopausal women. Beef is not high in calcium or vitamin D. Although 20 minutes in the sun each day provides vitamin D for most women, postmenopausal women should take supplemental vitamin D doses of 800 to 1000 IU per day. Although estrogen replacement may protect the woman against bone loss and fractures, it is no longer given specifically to prevent osteoporosis because of increased risk of heart disease and breast or uterine cancer.
Which female patients are at risk for developing osteoporosis (select all that apply)? a. 60-year-old white aerobics instructor b. 55-year-old Asian American cigarette smoker c. 62-year-old black who takes estrogen therapy d. 68-year-old white who is underweight and inactive e. 58-year-old Native American who started menopause prematurely
b, d, e. Risk factors for osteoporosis include age >65 years, white or Asian ethnicity, cigarette smoking, low body weight, inactive lifestyle, and estrogen deficiency (either postmenopausal, or from premature or surgical menopause). Other factors include family history; diet low in calcium; vitamin D deficiency; excessive alcohol use; and long-term use of medications, such as corticosteroids, thyroid replacement, heparin, long-acting sedatives, or antiseizure drugs.
A patient with chronic osteomyelitis has been hospitalized for a surgical debridement procedure. What should the nurse explain to the patient is the reason for the surgical treatment? a. Removal of the infection prevents the need for bone and skin grafting. b. Formation of scar tissue has led to a protected area of bacterial growth. c. The process of depositing new bone blocks the vascular supply to the bone. d. Antibiotics are not effective against microorganisms that cause chronic osteomyelitis.
b. Chronic infection of the bone leads to formation of scar tissue from granulation tissue. This avascular scar tissue provides an ideal site for continued microorganism growth and is impenetrable to antibiotics. Surgical debridement is often necessary to remove the poorly vascularized tissue and dead bone, and to instill antibiotics directly to the area. Bone and skin grafting may be needed after surgical removal of infection if destruction is extensive. Involucrum is new bone laid down at the infection site, which seals off areas of dead bone (sequestra) that may hold microorganisms that spread to other sites. Antibiotics can be effective during acute osteomyelitis. Prevention of chronic osteomyelitis requires early antibiotic treatment.
During a follow-up visit to a patient with acute osteomyelitis treated with IV antibiotics, the home health nurse is told by the patient's wife that she can hardly get the patient to eat because his mouth is so sore. In assessing the patient's mouth, what is the most likely finding that the nurse should expect to find? a. A dry, cracked tongue with a central furrow b. White, curdlike membranous lesions of the mucosa c. Ulcers of the mouth and lips surrounded by a reddened base d. Single or clustered vesicles on the tongue and buccal mucosa
b. One of the most common adverse effects of prolonged and high-dose antibiotic therapy is overgrowth of Candida albicans in the oral cavity and genitourinary tract. These infections are marked by whitish-yellow, curdlike lesions of the mucosa. A dry, cracked, furrowed tongue is characteristic of severe dehydration and vesicles are characteristic of herpes simplex infections. Mouth and lip ulcers are characteristic of aphthous stomatitis (canker sores).
Which statement describes osteosarcoma? a. High rate of local recurrence b. Very malignant and metastasizes early c. Arises in cancellous ends of long bones d. Develops in the medullary cavity of long bones
b. Osteosarcoma, the most common primary bone cancer, occurs in the metaphyseal region of long bones of the arms, legs, or pelvis. It is extremely malignant, metastasizes rapidly, and is often brought to attention by injury. A high rate of local recurrence occurs with osteoclastoma that arises in the cancellous ends of long bones. Ewing's sarcoma develops in the medullary cavity of long bones.
A 24-year-old patient with a 12-year history of Becker muscular dystrophy is hospitalized with heart failure. What is an appropriate nursing intervention for this patient? a. Feed and bathe the patient to avoid exhausting the muscle. b. Reposition frequently to avoid skin and respiratory complications. c. Provide hand weights for the patient to exercise the upper extremities. d. Use orthopedic braces to promote ambulation and prevent muscle wasting.
b. Promoting muscle activity is important in any patient with muscular dystrophy. However, when the disease has progressed to cardiomyopathy or respiratory failure, activity must be balanced with oxygen supply. At this stage of the disease, care should be taken to prevent skin or respiratory complications. The patient should be encouraged to perform as much self-care and exercise as energy allows, but this will be limited.
A patient with osteomyelitis has a nursing diagnosis of risk for injury. What is an appropriate nursing intervention for this patient? a. Use careful and appropriate disposal of soiled dressings. b. Gently handle the involved extremity during movement. c. Measure the circumference of the affected extremity daily. d. Range-of-motion (ROM) exercise every 4 hours to the involved extremity.
b. The patient with osteomyelitis is at risk for pathologic fractures at the infection site because of weakened, devitalized bone so careful handling of the extremity is needed. Careful handling of dressings is needed to prevent the spread of infection to others but is not related to preventing injury to this patient. Splints may be used to immobilize the limb. Edema is not a common finding in osteomyelitis. Range-of- motion (ROM) exercises will be limited because of the possibility of spreading infection.
A laminectomy and spinal fusion are done on a patient with a herniated lumbar intervertebral disc. During the postoperative period, which assessment finding is of most concern to the nurse? a. Paralytic ileus b. Urinary incontinence c. Greater pain at the graft site than at the lumbar incision sited. d. Leg and arm movement and sensation unchanged from preoperative status
b. Urinary incontinence after spinal surgery may indicate nerve damage and should be reported to the HCP. Paralytic ileus is not unexpected after this type of surgery. Pain at the graft site, usually the iliac crest or the fibula, is more often severe than pain at the fused area. Although movement and sensation of the arms and legs should not be more impaired than before surgery, deficits are not often relieved immediately after surgery.
What are characteristics of Paget's disease (select all that apply)? a. Results from vitamin D deficiency b. Loss of total bone mass and substance c. Abnormal remodeling and resorption of bone d. Most common in bones of spine, hips, and wrists e. Generalized bone decalcification with bone deformity f. Replacement of normal marrow with vascular connective tissue
c, f. Paget's disease involves abnormal remodeling and resorption of bone with replacement of normal marrow with vascular connective tissue. Osteoporosis is loss of total bone mass and substance with abnormal remodeling and resorption of bone; it is most common in bones of the spine, hips, and wrists. Osteomalacia results from vitamin D deficiency and causes generalized bone decalcification with bone deformity.
Before repositioning the patient on the side after a lumbar laminectomy, what should be the nurse's first action? a. Raise the head of the bed 30 degrees. b. Have the patient flex the knees and hips. c. Place a pillow between the patient's legs. d. Have the patient grasp the side rail on the opposite side of the bed.
c. After spinal surgery, patients are logrolled to maintain straight alignment of the spine. This involves turning the patient with a pillow between the legs and moving the body as a unit. The head of the bed is usually kept flat and the legs are extended.
A patient who had an open fracture of the humerus 2 weeks ago is having increased pain at the fracture site. To identify a possible causative agent of osteomyelitis at the site, what diagnostic test should the nurse expect? a. X-rays b. CT scan c. Bone biopsy d. White blood cell (WBC) count and erythrocyte sedimentation rate (ESR)
c. Because large doses of appropriate antibiotics are needed in the treatment of acute osteomyelitis, it is important to identify the causative microorganism. The definitive way to determine the causative agent is by bone biopsy or biopsy of the soft tissue surrounding the site. The other tests may help establish the diagnosis but do not identify the causative agent.
In promoting healthy feet, which factor does the nurse recognize as associated with most foot problems? a. Poor foot hygiene b. Congenital deformities c. Improperly fitting shoes d. Peripheral vascular disease
c. Poorly fitted shoes selected for fashion rather than comfort are the primary factor in the development of foot problems. A few congenital problems predispose to foot problems. Poor hygiene in patients with peripheral vascular disease may lead to foot infections but these factors are in the minority compared with the effect of ill-fitting shoes.
The patient has lateral angulation of the large toe toward the second toe. What should the nurse know will be included in the treatment? a. Metatarsal arch support b. Trimming with a scalpel after softening c. Surgery to remove the bursal sac and bony enlargement d. Intraarticular corticosteroids and passive manual stretching
c. This patient has a hallux valgus (bunion) that will be treated surgically by removing the bursal sac and bony enlargement and correcting the lateral angle of great toe. Metatarsal arch support is conservative treatment for hammer toe. A corn is trimmed with a scalpel after softening. Intraarticular corticosteroids and passive manual stretching are conservative treatment for hallux rigidus from osteoarthritis.
After 7 days of IV antibiotic therapy, a patient with acute osteomyelitis of the tibia is prepared for discharge from the hospital. The nurse determines that additional instruction is needed when the patient makes which statement? a. "I will need to continue antibiotic therapy for 4 to 6 weeks. "b. "I should notify the health care provider (HCP) if the pain in my leg becomes worse." c. "I shouldn't bear weight on my affected leg until healing is complete." d. "I do not need to do anything special while taking the antibiotic therapy."
d. Activities, such as exercises that increase circulation and serve as stimuli for the spread of infection, should be avoided by patients with acute osteomyelitis. Oral or IV antibiotic therapy is continued at home for 4 to 6 weeks. The HCP should be notified if increased pain occurs. Weight bearing is contraindicated to prevent pathologic fractures. Monitoring for side effects and complications of antibiotic therapy must be done.
What does radicular pain that radiates down the buttock and below the knee, along the distribution of the sciatic nerve, generally indicate? a. Cervical disc herniation b. Acute lumbosacral strain c. Degenerative disc disease d. Herniated lumbar disc disease
d. Lumbar disc herniation is generally indicated by radicular pain radiating down the buttock, below the knee, and along the distribution of the sciatic nerve. Cervical disc disease has pain radiating into the arms and hands. Acute lumbosacral strain causes acute low back pain. Degenerative disc disease is a structural degeneration of discs that often occurs with aging and results in intervertebral discs losing their elasticity, flexibility, and shock-absorbing capabilities.
Which type of bone tumor is a benign overgrowth of bone and cartilage that may transform into a malignant form? a. Enchondroma b. Osteoclastoma c. Ewing's sarcoma d. Osteochondroma
d. Osteochondroma is a benign overgrowth of bone and cartilage near the end of the bone at the growth plate, especially in long bones, pelvis, or scapula. It may transform to a malignant form. Enchondroma is a benign intramedullary cartilage tumor found in a cavity of a single hand or foot bone. Osteoclastoma is a benign bone tumor with a high rate of recurrence but does not become malignant. Ewing's sarcoma develops in the medullary cavity of long bones, especially the femur, humerus, pelvis, and tibia.
