Wk 4- Musculoskeletal Disorders

A patient who has Paget's disease is receiving calcitonin-salmon [Miacalcin] nasal spray. A nurse should expect the patient to have which therapeutic response if the medication is having the desired effect?

A decrease in bone pain Calcitonin is used to treat both osteoporosis and Paget's disease, which is characterized by increased bone resorption, skeletal abnormalities, and pain. Calcitonin acts to inhibit the activity of osteoclasts, thereby reducing bone resorption of calcium and thus bone pain. Because of the reduced bone turnover, the alkaline phosphatase and calcium levels in the blood are lowered. Treatment should include an adequate intake of vitamin D.

A nurse administers a new order for probenecid to a patient with gout and an infection. Which action will the nurse take?

Encourage an initial daily consumption of 3 L of fluid The risk of kidney damage can be minimized by alkalinizing (not acidifying) the urine and by consuming 2.5 to 3 L of fluid daily during the first few days of treatment. Administration with food decreases gastrointestinal upset. Probenecid may be purposefully employed to prolong the effects of penicillins and cephalosporins (by delaying their excretion by the kidneys) so this should not be avoided.

A patient is receiving adalimumab [Humira] for rheumatoid arthritis. Which patient teaching is priority?

Give subQ in the abdomen or anterior thigh. Teach patients and caregivers how to administer subQ injections, using either a syringe or an auto-injector. Instruct patients to: (1) inject medication into the abdomen or anterior thigh, (2) rotate the injection site, and (3) avoid areas where the skin is tender, bruised, red, or hard.

A patient is taking glucocorticoids and methotrexate [Rheumatrex] for rheumatoid arthritis. Which goal is the priority?

Reduce risk of infection Both glucocorticoids and methotrexate [Rheumatrex] suppress immune function, so the primary goal should be to reduce the risk of infections.

When evaluating the effects of probenecid, the nurse should monitor which laboratory result?

uric acid level Probenecid acts on the renal tubules to increase uric acid excretion, and plasma urate levels are reduced as a result. The sodium level, hemoglobin, and blood pH are not affected by probenecid.

A nurse is teaching a patient about ibandronate [Boniva]. Which information is essential to include in the teaching session?

"Do not eat anything for at least 60 minutes after taking this medicine." After dosing, ibandronate [Boniva] requires 60 minutes before eating and 60 minutes remaining upright. Ibandronate [Boniva] can only be taken with water. Taking right before bedtime would require lying down, an action that is contraindicated for ibandronate [Boniva] for at least 60 minutes or longer.

A postmenopausal patient is taking oral calcium salts. Which information from the patient requires follow-up from the nurse?

"I take my calcium with a spinach salad." Taking calcium with spinach will decrease absorption, so this needs to be corrected. Certain foods contain substances that can suppress calcium absorption. One such substance—oxalic acid—is found in spinach, rhubarb, Swiss chard, and beets. All the other statements are appropriate and do not need follow-up. Calcium citrate is especially good, owing to high solubility. To help ensure adequate absorption, no more than 600 mg should be consumed at one time. Phytic acid, another depressant of calcium absorption, and insoluble fiber, which also hampers absorption, are present in bran and whole-grain cereals. Oral calcium supplements should not be administered with these foods.

A patient is prescribed calcium gluconate for treatment of hypocalcemia. Which statement by the patient indicates a need for further teaching?

"I will take the calcium 1 hour before eating." Dosing of calcium with or after meals, not before, promotes absorption of the medication; therefore, further patient teaching is necessary. Calcium salts should be taken with a large glass of water. Foods to be avoided include spinach, Swiss chard, beets, bran, and whole-grain cereals. Patients should be taught the symptoms of hypercalcemia such as nausea, vomiting, constipation, urinary frequency, lethargy, and depression and should promptly notify the healthcare provider if these occur.

Which patient statement indicates to the nurse that the patient correctly understands the discharge instructions regarding alendronate [Fosamax]?

"I will take the medication on an empty stomach and not lie down for 30 minutes." To maximize bioavailability, alendronate [Fosamax] should be taken in the morning before breakfast (ie, on an empty stomach). To minimize the risk of esophagitis, patients should be instructed to (1) take alendronate [Fosamax] with a full glass of water, (2) remain upright (sitting or standing) for at least 30 minutes, and (3) avoid chewing or sucking alendronate [Fosamax] tablets. Decreasing dairy intake is not indicated. The medication does not directly relieve bone pain caused by osteoporosis.

Prior to administering etanercept [Enbrel] to a pediatric patient with rheumatoid arthritis, which question is priority for the nurse to ask the child's parent?

"Is your child current for vaccinations?" Inform parents that pediatric vaccinations should be current before therapy with etanercept antagonist [Enbrel] starts. It is not important if the child has fallen, plays video games, or has gone to the bathroom.

Which statement by a patient indicates to the nurse that further teaching about tiludronate [Skelid] is required?

"Taking Maalox three times a day will help reduce heartburn from taking the Skelid." Maalox contains magnesium, which greatly reduces the absorption of tiludronate; further teaching is necessary if the patient intends to take Maalox three times a day. If an isolated dose of Maalox must be taken, it should not be administered within 2 hours of taking tiludronate. Tiludronate should be taken with a full glass of water. Aspirin should be avoided for 2 hours after taking tiludronate because it reduces the drug's absorption. Food should not be consumed for 2 hours before or after taking tiludronate.

A nurse is teaching a patient with chronic tophaceous gout who is scheduled to start taking allopurinol [Zyloprim]. Which statement should the nurse include in the teaching?

"You may notice an increase in your pain attacks in the first month." Allopurinol inhibits xanthine oxidase to reduce uric acid levels in chronic tophaceous gout. During the first months of treatment, it may increase the incidence of acute gouty arthritis. Allopurinol lacks anti-inflammatory and analgesic actions and is not useful in an acute gout attack. Plasma levels of uric acid are evaluated. To prevent renal injury, fluid intake should be increased.

A nurse instructs a patient at risk for developing osteoporosis to implement which measure(s) to maximize bone strength? Select all that apply.

Avoid smoking and excessive alcohol Engage in regular weight-bearing exercise Ensure a daily intake of calcium and vitamin D The risk of osteoporosis can be minimized through a sufficient intake of calcium and vitamin D. Bone health is promoted by regular weight-bearing exercise such as walking, jogging, and dancing. Avoiding smoking and excessive alcohol intake are also healthy activities conducive to bone strength. Bone resorption can be reduced with estrogen replacement therapy through inhibition of osteoclast activity. However, because of new information about the benefits and risks of estrogen, prolonged replacement is no longer considered appropriate for most women. As a predictor of fracture risk, BMD testing is recommended for all women after a certain age.

A nurse is teaching adolescents about bone health. Which information should be included in the teaching session? Select all that apply.

Avoid smoking. Avoid excessive alcohol Perform regular weight-bearing exercise Lifestyle measures that promote bone health are: (1) performing regular weight-bearing exercises (walking, yoga, dancing, racquet sports, weight lifting, stair climbing), (2) avoiding excessive alcohol, and (3) avoiding smoking. Adolescents need 1300 mg of calcium a day. Bone mineral density testing is not recommended for children or adolescents.

A nurse obtains a health history from a patient who has gout and is taking a glucocorticoid. The nurse should follow up on which finding?

Blood glucose level of 140 mg/dL Glucocorticoids are very effective in the treatment of acute gout attacks and are preferred for patients who are not candidates for or are unresponsive to nonsteroidal anti-inflammatory drugs. Because of their effects on carbohydrate metabolism, glucocorticoids should be avoided in patients prone to hyperglycemia. Flushing and urticaria are not associated with glucocorticoid use. The heart rate is not affected by glucocorticoids. Glucocorticoids cause weight gain, not weight loss.

A female patient is to start treatment with teriparatide [Forteo] for osteoporosis. The nurse assesses the patient's history for which disorder that would be a contraindication to treatment?

Bone cancer Teriparatide is a form of parathyroid hormone that acts to increase bone formation when it is given by daily subcutaneous injections. It has few serious side effects but has been shown in animal studies to cause bone cancer. It should be avoided by patients with bone cancer or metastases. Multiple sclerosis, myocardial infarction, and glaucoma are not contraindications to treatment with teriparatide.

A nurse is teaching the staff about colchicine [Colcrys]. Which information from the staff would require follow up?

Colchicine [Colcrys] is currently considered a first-line drug for gout. The option "Colchicine [Colcrys] is currently considered a first-line drug for gout" is incorrect and indicates more teaching is needed. In the past, colchicine [Colcrys] was considered a first-line drug for gout. However, owing to the availability of safe and effective alternatives, its use has declined. All the remaining options are correct and do not indicate a need for more teaching.

A patient is ordered intravenous ibandronate [Boniva] for treatment of postmenopausal osteoporosis. What is a contraindication to administration of the drug?

Concurrent administration of cyclosporine because of a history of liver transplantation Ibandronate should not be administered to patients who take other nephrotoxic drugs. Cyclosporine is nephrotoxic. Other contraindications to administration include a serum creatinine level above 2.3 mg/dL and a creatinine clearance below 30 mL/min. A BUN of 20 mg/dL is within normal limits.

A nurse is monitoring a patient who is receiving an intravenous infusion of rituximab [Rituxan] for severe rheumatoid arthritis. Which finding is a complication of this treatment that would require the nurse to stop the infusion?

Hypotension Rituximab can cause infusion-related hypersensitivity reactions within 30 minutes of initiation. Symptoms include hypotension, bronchospasm, hypoxia, and cardiogenic shock. Nosebleeds, seizure activity, and hypoglycemia are not associated with infusion reactions of rituximab.

After reviewing the chart of a patient taking leflunomide [Arava] for rheumatoid arthritis, which finding will cause the nurse to follow up?

Liver injury Leflunomide [Arava] is hepatotoxic. Patients should be informed about signs of liver injury—abdominal pain, fatigue, dark urine, and jaundice—and advised to report them immediately. Hydroxychloroquine [Plaquenil] can cause retinal damage. Gold salts [Ridaura] cause intense pruritus and peripheral neuritis.

A nurse monitors the calcium level of a patient who has had a thyroidectomy. The nurse should note which finding if the patient's calcium level is 6.4 mg/dL?

Muscle twitching and tetany Low calcium levels may be the result of inadvertent removal of the parathyroid gland during a thyroidectomy, leading to a lack of parathyroid hormone (PTH). This produces hypocalcemia and symptoms of tetany, muscle twitching, and neuromuscular excitability. Nausea and vomiting, lethargy, and confusion are symptoms of hypercalcemia. Dull, aching bone pain may be associated with osteomalacia and vitamin D insufficiency.

The nurse teaches a patient with gout that naproxen [Naprosyn] is an agent of first choice for treatment over colchicine. The nurse should use which rationale for the teaching?

Naproxen achieves more predicable pain relief with fewer side effects. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to suppress inflammation in gout. Compared with colchicine, NSAIDs are better tolerated and have more predictable effects. Because safe, effective alternatives are available, the use of colchicine has declined. The treatment time with NSAIDs is brief because pain relief occurs within 24 hours and swelling subsides over a few days. Hyperglycemia is more of a concern when glucocorticoids are used. NSAIDs do not affect uric acid levels.

A nurse administered prednisone to a patient with gout. Which finding indicates a therapeutic effect of the drug?

Pain is decreased. Glucocorticoids (eg, prednisone), given by mouth or intramuscularly, are highly effective for relieving an acute gouty attack, although nonsteroidal anti-inflammatory drugs are generally preferred. Prednisone does not decrease uric acid; it is not used for chronic gout. Hyperglycemia is an adverse effect of prednisone. Because of their effects on carbohydrate metabolism, glucocorticoids should be avoided in patients prone to hyperglycemia.

A nurse is administering raloxifene [Evista] to a postmenopausal patient for osteoporosis. Which risks should the nurse monitor for in this patient? Select all that apply.

Risk for stroke Risk for pulmonary embolism Risk for deep vein thrombosis Risk for extended periods of immobility The U.S. Food and Drug Administration (FDA) has issued black box warnings for raloxifene [Evista]. These warnings address risks of deep vein thrombosis (DVT), pulmonary embolism (PE), and the risk of death due to stroke. Because inactivity promotes DVT, patients should discontinue raloxifene [Evista] at least 72 hours before prolonged immobilization. Pregnancy would not be a risk for a postmenopausal patient.

A nurse administered a drug to a patient for osteoporosis. The nurse explained that the drug would increase bone formation. Which drug did the nurse administer?

Teriparatide [Forteo] Teriparatide [Forteo] is the only drug for osteoporosis that increases bone formation. Tiludronate [Skelid] is an oral bisphosphonate approved only for Paget's disease of bone. Edetate disodium [Endrate] is a chelating agent that binds calcium in the blood, causing serum calcium levels to decrease. Calcitonin-salmon [Miacalcin] decreases serum calcium levels by inhibiting bone resorption and increasing calcium excretion.

A nurse should establish which outcome(s) when planning care for optimal bone health in a child? Select all that apply.

The child has daily exposure to sunlight. The child has absence of skeletal deformities. The child takes a multivitamin containing vitamin D. The child has a daily intake of cereal, cheese, and milk. Vitamin D is needed to ensure calcium absorption. It is obtained through the diet especially in vitamin D-fortified cereals, milk, and cheese, as well as with exposure to sunlight. The American Academy of Pediatrics recommends that children take 400 international units/day of vitamin D in a multivitamin to prevent abnormal skeletal conditions such as rickets. A DEXA scan is used to measure bone mineral density when diagnosing osteoporosis, a bone condition common in adults.

A patient is diagnosed with rheumatoid arthritis. After administering golimumab [Simponi], the nurse learns that the patient has a history of tuberculosis. What possible consequence will the nurse anticipate in the patient?

The patient may have reactivation of tuberculosis. Golimumab [Simponi] may cause reactivation of tuberculosis in a patient who has had previous tuberculosis. Hypertension is the adverse effect of tocilizumab [Actemra] or leflunomide [Arava]. Golimumab [Simponi] causes reactivation of hepatitis when administered to a patient who has had a previous attack of hepatitis. Golimumab [Simponi] may increase the risk of lymphoma and other malignancies, but the question is asking about a history of tuberculosis.

Febuxostat [Uloric] will be administered by the nurse in which patient situation?

When the patient has chronic gout Febuxostat [Uloric] is an alternative to allopurinol [Zyloprim] for chronic gout. Febuxostat [Uloric] lacks anti-inflammatory and analgesic actions, so it is not useful against an acute gouty attack.

A patient with rheumatoid arthritis is receiving infliximab [Remicade]. Which adverse effects will the nurse monitor for in this patient? Select all that apply.

chills fever dyspnea headache Infusion reactions are common, manifesting as flu-like symptoms, headache, fever, chills, dyspnea, hypotension, skin reactions, and gastrointestinal disturbance. Hypertension does not occur.

In addition to local joint pain and limited range of motion, a nurse should recognize which finding(s) as systemic manifestations of rheumatoid arthritis? Select all that apply.

fatigue vasculitis corneal ulcers Rheumatoid arthritis is manifested by joint stiffness and pain secondary to an autoimmune disorder in which damaging compounds attack the articular cartilage. In addition, systemic manifestations of fatigue, corneal ulcers, and vasculitis may occur.