Ch 44 Musculoskeletal & Arthritis and TJA ch 46

2 of 11 A client is scheduled to have a bone scan for a suspected bone tumor. What statement by the nurse is correct about the procedure for this test? "It sees sound waves to produce an image of the skeleton." "It requires an injected radioactive material to view entire skeleton." 'It requires an injected iodine-based contrast medium to view the bone." "It relies on magnetic waves to help produce the image of the bone."

✅"It requires an injected radioactive material to view entire skeleton." A bone scan produces images of the entire skeleton through the use of a radioactive material that is used prior to imaging. Chapter 44 - Assessment of the Musculoskeletal System iggy

A client was recently diagnosed with osteoarthritis and asks the nurse which over-the-counter drug would be the best to take? What would the nurse's recommendation be? Ibuprofen Acetaminophen Tramadol Gabapentin

✅Acetaminophen Several major medical organizations, including the American Pain Society and OARSI committee recommend acetaminophen as the primary drug of choice. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

9 of 11 The nurse is using a common scale to grade a client's muscle strength. The client is able to complete range of motion (ROM) only with gravity eliminated. Which grade does the nurse document in this client's record? 0 3 1 2

✅2 The nurse documents a grade of two (2) for this client because it indicates poor muscle strength. The client can complete ROM only with gravity eliminated. Grade zero (0) indicates no evidence of muscle contractility. Grade one (1) indicates trace muscle strength and shows that the client has no joint motion and slight evidence of muscle contractility. Grade three (3) indicates fair muscle strength, where the client can complete ROM against gravity Chapter 44 - Assessment of the Musculoskeletal System iggy

11 of 11 The nurse is reviewing the laboratory test results for a client who was diagnosed with muscular dystrophy (MD) as a child. Which lab results will the nurse expect to be elevated? (Select all that apply.) Select all that apply. Alkaline phosphatase Aldolase Calcium Lactic dehydrogenase (LDH) Creatine kinase (CK-MM)

✅Alkaline phosphatase ✅Aldolase ✅Lactic dehydrogenase (LDH) ✅Creatine kinase (CK-MM) Muscular dystrophy is a group of genetically linked diseases that cause chronic skeletal muscle weakness and organ dysfunction due to smooth muscle involvement. Therefore, this disease affects muscles which cause elevations of muscle enzymes. Chapter 44 - Assessment of the Musculoskeletal System iggy

1. The nurse is caring for a client with severe osteoarthritis. What will the nurse anticipate as the client's priority problem? A. Joint pain B. ADL dependence C. Risk for falls D. Muscle stiffness

✅Answer: A Rationales: Osteoarthritis indicates a joint disease in which bone cartilage degenerates causing joint pain and secondary inflammation (Choice A). The client often experiences muscle stiffness which is not as uncomfortable as joint pain (Choice D). Clients who have severe osteoarthritis are not necessarily dependent in ADLs or at risk for falling (Choice B and C). Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

The primary health care provider prescribes daily celecoxib for a client experiencing persistent joint pain in both knees. Which health teaching will the nurse provide for the client regarding this drug for long term pain control? Select all that apply. A.​"Take the prescribed drug before breakfast each day." B.​"Report any sign of bleeding, including bloody or dark, tarry stool." C.​"Do not take other NSAIDs while on celecoxib." D.​"Report any major changes in the amount of urine you excrete each day." E.​"Follow up with lab tests to assess liver function."

✅Answer: B, C, D Rationales: Celecoxib is a COX-2 inhibiting NSAID and therefore can cause many adverse effects including GI symptoms, such as bleeding (Choice B), and acute kidney injury which is manifested by decreased urinary output (Choice D). Other NSAIDs should be avoided to reduce potential adverse effects (Choice C). All NSAIDs should be taken with meals or food to decrease GI effects, making Choice A the wrong response. Lab tests to measure liver function are more likely requested for patients taking acetaminophen, so Choice E is not appropriate for celecoxib therapy. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

3. The nurse is assessing a client who has late-stage rheumatoid arthritis. Which assessment findings would the nurse expect for this client? Select all that apply. A. Joint inflammation B. Severe weight loss C. Bony nodules D. Joint deformities E. Sjogren's syndrome

✅Answer: B, D, E Rationales: Although rheumatoid arthritis (RA) is an inflammatory disease, clients with late-stage disease have joint deformity rather than inflammation (Choice A and D). Bony nodules occur in clients who have osteoarthritis; subcutaneous nodules are more common in clients with RA (Choice C). Severe weight loss and possibly Sjogren's syndrome are common in clients with late-stage RA (Choice B and E). Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

2. The nurse is caring for a client who had a posterolateral total his arthroplasty yesterday. For which commonly occurring postoperative complication will the nurse monitor for this client? A. Pneumonia B. Paralytic ileus C. Wound dehiscence D. Surgical hip dislocation

✅Answer: D Rationales: Even with aggressive preventive interventions, the client who has a total hip arthroplasty (THA) is at most risk for the common complication of venous thromboembolism. The other choices are much less common for clients having a THA, and would be seen in clients having other types of surgery. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

The nurse is preparing a client for a total hip arthroplasty today. What IV antibiotic would the nurse likely administer if the client has no drug allergies? Penicillin Clindamycin Vancomycin Cefazolin

✅Cefazolin Cephalosporins are the drug class of choice for clients without allergies who are having a total joint arthroplasty. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

The nurse is developing a health teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? Take up knitting to slow down joint degeneration. Eat at least 2 yogurts every day. Wear supportive shoes at all times. Begin a jogging or running program.

✅Wear supportive shoes at all times. Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints. Running and running promotes stress on joints and should be avoided. Repetitive stress activities such as knitting or typing should be avoided for prolonged periods. No single food can cure OA; a well-balanced diet should be recommended. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. Avoid acetaminophen in over-the-counter medications. b. It may take several weeks to become effective on pain. c. Pregnancy and breast-feeding are not affected by MTX. d. Stay away from large crowds and people who are ill. e. You may find that folic acid, a B vitamin, reduces side effects.

ANS: A, B, D, E MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.

Which diagnostic test requires the nurse to know whether the client is allergic to iodine-based contrast? Arthroscopy Electromyography (EMG) Computed tomography (CT) Tomography

✅Computed tomography (CT) A CT scan creates three-dimensional images and may be done with iodine-based contrast. Arthroscopy, EMG, and tomography do not use iodine-based contrast. Chapter 44 - Assessment of the Musculoskeletal System iggy

The nurse is teaching a client preparing to have a total knee replacement about interventions to help prevent surgical infection. What interventions would the nurse include in this teaching? (Select all that apply.) Select all that apply. Using nasal mupirocin for at least a week before surgery Avoiding sleeping with pets in the client's bed Showering the night before and the morning of surgery with chlorhexidine Giving antibiotics before and after surgery for at least 3 days Sleeping on clean linen wearing clean nightwear

✅Using nasal mupirocin for at least a week before surgery All of these interventions are used to help prevent infection except for the use of long-term antibiotics. Long-term antibiotic therapy is used to treat rather than prevent postoperative infection. ✅Avoiding sleeping with pets in the client's bed All of these interventions are used to help prevent infection except for the use of long-term antibiotics. Long-term antibiotic therapy is used to treat rather than prevent postoperative infection. ✅Showering the night before and the morning of surgery with chlorhexidine ✅Sleeping on clean linen wearing clean nightwear All of these interventions are used to help prevent infection except for the use of long-term antibiotics. Long-term antibiotic therapy is used to treat rather than prevent postoperative infection. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty. Which of the following statements by the client should the nurse identify as understanding of the teaching? "I will wear a continuous movement machine on my knee for 24 hours a day." "I should avoid taking NSAID medications for pain after surgery." "I should wear elastic stockings on both of my legs." "I will begin exercising my legs the day after surgery."

"I will wear a continuous movement machine on my knee for 24 hours a day." The nurse should instruct the client that a continuous passive motion (CPM) machine is usually prescribed for a few hours at a time several times a day. Not all clients are prescribed CPM therapy following total knee arthroplasty. "I should avoid taking NSAID medications for pain after surgery." The nurse should remind the client that pain will be initially controlled with epidural or patient-controlled analgesia and supplemented by other analgesic medications, including NSAIDs. ✅"I should wear elastic stockings on both of my legs." The purpose of elastic stockings is to prevent venous thromboembolism, which is a common complication following orthopedic surgery. Therefore, the nurse should identify this statement as understanding of the teaching. "I will begin exercising my legs the day after surgery." The nurse should instruct the client to begin leg exercises while in bed during the immediate postoperative period, including heel pumps and quadriceps setting exercises.

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best? a. Lets ask the provider about increasing your pain pills. b. Hold ice bags against your hands before quilting. c. Try a paraffin wax dip 20 minutes before you quilt. d. You need to stop quilting before it destroys your fingers.

Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a hot or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.

The nurse is caring for a client with osteoarthritis (OA) in the left knee. What factor does the nurse suspect is the most likely cause of this client's OA? Trauma to the joint Aging Osteoporosis Familial history

✅Trauma to the joint The client has OA in one knee which suggests that the client has secondary OA rather than primary disease. Secondary OA occurs as a result of joint injury or obesity Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

3 of 11 The nurse is completing an admission assessment on a client scheduled for arthroscopic knee surgery. Which information will be most essential for the nurse to report to the health care provider? Allergy to shellfish and iodine Knee pain at a level of 9 (0-10 scale) Previous surgery on the other knee Warm, red, and swollen knee

✅Warm, red, and swollen knee Findings such as swelling, heat, and redness may indicate infection in the knee joint and is most essential for the nurse to report to the health care provider. These findings will help the health care provider determine whether there may be a need to cancel the procedure. Having knee pain before surgery is not unexpected but will not affect whether the client will have surgery. Having previous surgery on the other knee does not preclude the client from having this surgery. Chapter 44 - Assessment of the Musculoskeletal System iggy

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the clients culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

A. Assess the clients culture more thoroughly. The nurse needs a more thorough understanding of the clients culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.

. Cyclosporine (Sandimmune®) and methotrexate (Rheumatrex®) are prescribed for a client with severe rheumatoid arthritis. Which points should a nurse address when teaching the client about these medications? SELECT ALL THAT APPLY. Drinking grapefruit juice is best because the medications' effects are enhanced. Keep well hydrated to maximize the therapeutic effects of methotrexate. Avoid use of St. John's wort, echinacea, and melatonin, as these may interfere with immunosuppression. These medications are administered weekly by subcutaneous injection. Both methotrexate and cyclosporine suppress the immune system.

ANSWER: 2, 3, 5 Adequate hydration minimizes the risk of adverse effects. St. John's wort decreases cyclosporine levels. Echinacea and melatonin interact with cyclosporine to alter immunosuppression. Methotrexate and cy- closporine both have immunosuppressive effects. Grapefruit juice should be avoided because it can increase the concentration of cyclosporine. Methotrexate and cyclosporine can be taken orally instead of by injection. It is incorrect that both medications are taken weekly. Only methotrexate is taken weekly, whereas cyclosporine is usually taken twice daily.

A nurse is performing a musculoskeletal assessment on an older adult. What normal physiologic changes of aging does the nurse expect? Select all that apply. A.​ Muscle atrophy B.​ Slowed movement C.​ Kyphosis D.​ Arthritis E.​ Widened gait F.​ Decreased joint range-of-motion

Answer: A, B, C, D, E, F Rationale: As listed in the Older Adult Health Considerations box, all of these assessment findings are common physiologic changes associated with the aging process Chapter 44 - Assessment of the Musculoskeletal System iggy

1.The nurse is preparing to teach a client about how to promote musculoskeletal health. Which statements will the nurse include in the teaching plan? Select all that apply. A. "If you smoke, you need a smoking cessation plan." B. "Avoid drinking excessive alcohol." C. "Be sure to take in enough calcium and Vitamin D." D. "Avoid high-risk activities that could cause an accident." E. "Include weight-bearing exercise like walking on a regular basis."

Answers: A, B, C, D, E Rationales: All of these choices are correct because they can help promote musculoskeletal health. Chapter 44 - Assessment of the Musculoskeletal System iggy

A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis? Bulging in the area over the surgical incision Shortening of the right leg Sensation of warmth over the surgical incision Pallor following elevation of the right leg

Bulging in the area over the surgical incision The nurse should not expect visible bulging following dislocation of the prosthesis. ✅Shortening of the right leg The nurse should monitor the client for shortening of the affected leg as an indication of dislocation of the prosthesis. Other findings include increased hip pain, inability to move the extremity, and rotation of the hip internally or externally. Sensation of warmth over the surgical incision The nurse should not expect a sensation of warmth over the surgical incision following dislocation of the prosthesis. A sensation of warmth or heat can indicate infection of the joint. Pallor following elevation of the right leg The nurse should not expect pallor following elevation of the right leg following dislocation of the prosthesis. This finding is expected for a client who has impaired arterial circulation.

A 62-year-old female client is attending a community health fair. A health fair nurse recommends that the client make an appointment with a physician and ask that a DEXA (dual-energy x-ray absorptiometry) scan be done to evaluate for osteoporosis because the client has many risk factors. Which risk factor likely influenced the health fair nurse's decision to recom- mend a DEXA scan? 1. Diabetes mellitus 2. Postmenopausal 3. Overweight 4. African American

Postmenopausal Major risk factors for osteoporosis include increased age, female sex, White or Asian race, family history of osteoporosis, and a thin body structure. Since osteoporosis is the most common metabolic disease, affecting 50% of women during their lifetime, it is important for women to be screened and begin appropriate treatment, if needed. Diabetes mellitus and being overweight are not risk factors for osteoporo- sis. Being overweight can contribute to the development of osteoarthritis.

A client returns to the post-anesthesia care unit (PACU) after an arthroscopy to repair a shoulder injury. What is the nurse's priority when caring for this client? A.​ Keep the affected arm elevated and immobilized. B.​ Ensure that the patient uses the patient-controlled analgesia (PCA) pump. C.​ Check the neurovascular status of the affected arm. D.​ Instruct the client to stay in bed for 24 hours.

✅ C. Check the neurovascular status of the affected arm. Postoperative swelling or bleeding can compress arterial and nerve supply to the entire arm. Therefore, performing a neurovascular assessment on the affected arm can detect any vascular or nerve changes that may need medical treatment. Choice A is also important to prevent increased swelling, but is not as important of a concern for the nurse. The client may or may not have a PCA pump (choice B) and would not need to stay in bed for 24 hours (choice D). Chapter 44 - Assessment of the Musculoskeletal System iggy

7 of 11 A client is scheduled to undergo closed magnetic resonance imaging (MRI) without contrast medium. Which information does the nurse give to the client before the test? "Do not eat or drink for 8 hours before the test." "It will be important to lie still in a reclined position for 20 minutes." "You can have the MRI if you have an internal pacemaker." "All jewelry and clothing with zippers or metal fasteners must be removed."

✅"All jewelry and clothing with zippers or metal fasteners must be removed." The nurse tells the client that all clothing with zippers or metal fasteners and all jewelry must be removed before undergoing MRI. The client having a closed MRI will lie still in a supine position for 45 to 60 minutes, not 20 minutes, and may require sedation. It is not necessary for the client to be NPO before an MRI. The client cannot undergo MRI when an internal pacemaker or any other metal object is present in the body. Chapter 44 - Assessment of the Musculoskeletal System iggy

The nurse is assessing an older client who has bony nodules on finger joints (Heberden and Bouchard nodes). What priority question would the nurse want to ask as part of the client interview? "When did your bony nodules develop?" "How do you feel about having these bony nodules?" "Are you able to independently perform ADLs?" "Are your bony nodules painful or tender?

✅"Are you able to independently perform ADLs?" As a result of the client having bony nodules in his or her hands, the most important question for the nurse to ask is to determine if the client is ADL independent. The nurse would also ask the other questions, but they are not the first questions to be asked. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

8 of 11 The client asks what tool the physical therapist (PT) used to measure joint range of motion (ROM)? How would the nurse respond? "Goniometer" "Reflex hammer" "Tonometer" "Doppler device"

✅"Goniometer" A goniometer provides an exact measurement of flexion and extension or joint ROM. A Doppler device is used to check and find pulses. A reflex hammer is used to test and elicit reflexes and is used in neurologic examinations. A tonometer is used to measure tension or pressure in the eye. Chapter 44 - Assessment of the Musculoskeletal System iggy

The nurse is planning health teaching for a client starting hydroxychloroquine for rheumatoid arthritis. What instruction would the nurse include in the teaching? "Be aware that the drug may cause secondary types of cancer." "Expect nausea and vomiting for the first week after starting the drug." "Have eye examinations every 6 months while on the drug." "Keep this medication in the refrigerator at all times."

✅"Have eye examinations every 6 months while on the drug." Hydroxychloroquine is an antimalarial drug with immune modulating and anti-inflammatory properties. Although side effects are usually mild, long-term use of the drug can cause vision problems. The client is taught to have an eye examination prior to starting the drug and every 6 months while on the drug to detect any visual changes. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

The nurse has provided health teaching for a female client starting on methotrexate (MTX) for early rheumatoid arthritis. What statement by the client indicates a need for further teaching? "I will try to avoid crowds because I could easily get an infection." "I will start folic acid supplements whichh can help decrease side effects." "I can drink alcohol in small amounts at night to help me relax." "I will use strict birth control while I am taking this drug."

✅"I can drink alcohol in small amounts at night to help me relax." All of these statements are correct about MTX except that the client needs to avoid all alcoholic beverages to prevent liver toxicity. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

A client is scheduled for magnetic resonance arthrography of the right knee to determine ligament damage. Which statement by the client indicates a need for further teaching? "I can take ibuprofen to help with any discomfort after the procedure." "I will need to use ice for a day or two after the procedure to prevent swelling." "My knee will be numbed before the needle is inserted into my joint." "I'll only be in the hospital overnight to get the procedure done."

✅"I'll only be in the hospital overnight to get the procedure done." This test does not require hospitalization. The client will receive local anesthesia where a needle will be inserted to inject a contract medium. After the test is performed, the client would want to use ice and NSAIDs or acetaminophen for discomfort and swelling. Chapter 44 - Assessment of the Musculoskeletal System iggy

A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly licensed nurse. Which of the following information should the nurse include about osteoarthritis? "Osteoarthritis is caused by autoimmune processes." "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." "Osteoarthritis affects other organ systems." "Osteoarthritis can impair a joint on a single side of the body."

✅"Osteoarthritis can impair a joint on a single side of the body." The nurse should identify unilateral joint involvement as a finding of osteoarthritis. A client who has RA experiences symmetrical joint impairment. "Osteoarthritis is caused by autoimmune processes." The nurse should identify aging as a risk factor that causes degenerative changes in osteoarthritis. RA is an autoimmune disease in which the body's immune system attacks itself. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." The nurse should expect an increased erythrocyte sedimentation rate for a client who has osteoarthritis. "Osteoarthritis affects other organ systems." The nurse should recognize that osteoarthritis is limited to the joints. RA is a systemic autoimmune disease, involving other body organs.

The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? "I do not know how long my wife will be able to take care of me at home." "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." "I do not know how much longer my neighbor can continue to help clean my house." "The bus is coming to pick me up from the senior center three times a week so I can play cards."

✅"The bus is coming to pick me up from the senior center three times a week so I can play cards." Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support. Caregiving responsibilities can be a source of stress; the client worrying about his wife's caregiving abilities does not indicate that the client is effectively coping. Routine tasks, such as doing dishes and laundry, need to be reassigned or effective pain management should be instituted before activities are undertaken to demonstrate effective coping. Neighbors are not reliable resources for in-home needs, and asking a neighbor to help does not indicate that the client is coping effectively. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

The nurse is preparing to give apixaban for a client who recently had a total knee arthroplasty. What does the nurse recognize as the advantage of this drug over other anticoagulants? The client does not need to have labs drawn for PT or INR. The client only needs to take the drug while in the hospital. The client is not at risk for bleeding or bruising. The client does not need to wear sequential compression devices.

✅The client does not need to have labs drawn for PT or INR. Apixaban is a newer factor Xa inhibitor that helps to prevent venous thromboembolism in clients who have a total knee arthroplasty. The client taking this drug will need to continue for several weeks after surgery and is at risk for bleeding or bruising. However, the drug does not affect PT or INR, so that the client does not need to have labs drawn. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

A 70-year old woman is admitted to the hospital with suspected streptococcal pneumonia. She continues to have an occasional cough, mild dyspnea, and a fever over 100 degrees F (37.8 degrees C) after a week of treatment with amoxicillin at home. The hospitalist prescribes IV levofloxacin 750 mg daily. The admitting nurse documents the following history and physical assessment data: --Has a 25-year history of rheumatoid arthritis (RA) and osteoarthritis --Was diagnosed with diabetes mellitus type 2 last year which is controlled by diet --Has a history of atrial fibrillation --Is retired and lives along in a senior housing apartment --Volunteers twice a week in the local library --Current medications include: ​- Etanercept 50 mg subcutaneously each week (self-administered) for RA ​- Leflunomide 10 mg orally each day for RA ​- Clopidogrel 75 mg orally each day for atrial fibrillation ​- Acetaminophen 500 mg orally as needed twice a day for OA pain --Has two children who live locally --Is able to perform ADLs independently although she has ulnar deviation and finger deformities in both hands --Uses a cane when not at home --Drives short distances to the grocery store and bank --Is alert and oriented --Reports occasional constipation --Reports current joint pain level is a 5 on a 0-10 pain scale; most painful joints are her feet and knees (states that her usual pain level is a 1-2 prior to hospital admission) --Reports occasional paresthesias in both feet --Has 1+ nonpitting edema in both feet --Current oral temperature = 100.8 degrees F (38.2 degrees C) --Current apical pulse = 82 --Resting respiratory rate = 32 breaths/minutes --Current blood pressure = 138/88 --Admitting WBC = 15,500/mm3 1.​What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) 2.​What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3.​Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4.​What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which actions are appropriate and those that should be avoided.) 5.​Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6.​What client assessment would indicate that the nurse's actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)

✅1. --Is over 65 years of age --Has a 25-year history of rheumatoid arthritis (RA) and osteoarthritis --Has a history of atrial fibrillation and recent diagnosis of diabetes mellitus type 2 --Current medications include: ​​- Etanercept 50 mg subcutaneously each week (self-administered) for RA ​​- Leflunomide 10 mg orally each day for RA ​​- Clopidogrel 75 mg orally each day for atrial fibrillation ​​- Acetaminophen 500 mg orally as needed twice a day for OA pain --Is able to perform ADLs independently although she has ulnar deviation and finger deformities in both hands --Uses a cane when not at home --Reports current joint pain level is a 5 on a 0-10 pain scale; most painful joints are her feet and knees --Is alert and oriented --Current oral temperature = 100.8 degrees F (38.2 degrees C) --Resting respiratory rate = 32 breaths/minutes (has had mild dyspnea) --Reports occasional cough --Admitting WBC = 15,500/mm3 ✅2. --Mild dyspnea, cough, and tachypnea --Fever --Increased WBC count --Persistent pain in lower extremities --Impaired mobility --Risk for additional infection --Risk for bleeding --Risk for increased healing time ✅3. --Dyspnea, cough, and tachypnea likely due to unresolved pneumonia --Fever and increased WBC count likely due to infection (pneumonia) --Infection may be the result of client taking enteracept (biologic response modifier) and older age (over 65 years) --Joint pain in lower extremities due to RA and/or OA --Impaired mobility requiring a cane to ambulate likely due to RA and/or OA --Risk for bleeding due to client taking clopidogrel (anti-platelet drug) --Risk for increased healing time due to drug therapy for RA which suppresses immunity and diabetes mellitus ✅4. --Need to improve ease of breathing and minimize cough --Need to manage joint pain --Need to resolve infection and prevent additional infection --Need to manage RA to prevent disease exacerbation --Need to prevent falling ✅5 --Keep client in sitting position to facilitate breathing. --Start oxygen via nasal cannula at 2-3 L/minute. --Place client on fall precautions, including staff assistance when client is out of bed. --Place client on bleeding precautions due to anti-platelet medication. --Use meticulous infection control measures to prevent acquiring additional infection. --Request continuation of the client's current drug regimen to prevent RA exacerbation and manage joint pain. --Monitor vital signs every 4 hours. --Continue to monitor WBC count during client's hospital stay. ✅6 --Client will not experience dyspnea. --Client will not experience a fall. --Client will not experience any signs of bleeding. --Systemic infection will resolve as evidenced by normal WBC, normal body temperature, and normal respiratory rate without cough --Client will not acquire additional infection while hospitalized. --Persistent pain will be controlled as evidenced by client report of pain as 2 on a 0-10 pain scale. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

A client had a left noncemented posterolateral total hip arthroplasty 2 days ago. Which statements will the nurse include in health teaching for the client? Select all that apply. A.​ "Practice leg exercises each day as instructed." B.​ "Take deep breaths and use incentive spirometry every 2 hours." C.​ "Be sure to cross your legs to be more comfortable in a chair." D.​ "Report sudden increased hip pain or rotation immediately to the nurse." E.​ "Stand on your right leg and pivot into the chair when getting out of bed."

✅Answer: A, B, D, E Rationales: The client who had a posterolateral surgical approach is at risk for hip dislocation and should be taught NOT cross his or her legs which cause adduction. Therefore, Choice C is an incorrect response. All clients having a total hip arthroplasty are at risk for clotting and leg exercises can help reduce that risk (Choice A). Taking deep breaths and using incentive spirometry are important for all surgical clients to prevent pneumonia or ateletasis (Choice B). Choice D is important for client teaching because these signs and symptoms may indicate hip dislocation. Clients with noncemented implants should not initially bear weight on the affected leg (Choice E). Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

Which assessment findings will the nurse expect for the client with early-stage rheumatoid arthritis? Select all that apply. A.​ Joint inflammation B.​ Subcutaneous nodules C.​ Severe weight loss D.​ Fatigue E.​ Thrombocytosis F.​ Anorexia

✅Answer: A, D, F Rationales: Subcutaneous nodules (Choice B), severe weight loss (Choice C) and thrombocytosis (Choice E) are all commonly seen in clients with late-stage, advanced RA. Joint inflammation (Choice A) is common in early disease and often occurs with client reports of fatigue and anorexia (Choices D and F). Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

An unlicensed assistive personnel (UAP) is assigned to care for a client who had a cemented total knee arthroplasty yesterday. Which observation by the UAP indicates a need for follow-up by the nurse? A.​ "The client's surgical knee is very swollen and discolored." B.​ "The client states that the surgical knee is very painful when moving it." C.​ "The client's lower leg on the surgical side is painful and red." D.​ "The client needs assistance with walking to the bathroom.

✅Answer: C Rationales: A client who had a TKA one-day ago is expected to have a swollen and discolored surgical knee that is very painful when moving. The client is also expected to need assistance with a walker and possibly a staff member when ambulating. Therefore, Choices A, B, and D do not require follow-up by the nurse. However, redness, pain, and possibly swelling of the lower leg may indicate deep vein thrombosis which requires follow-up and assessment by the nurse (Choice C). Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

2.Which serum laboratory finding is of concern for the nurse and should be reported to the primary health care provider? A. Calcium = 9 mg/dL (2.10 mmol/L) B. Phosphorus = 4.5 mg/dL (1.45 mmol/L) C. Lactate dehydrogenase = 150 units/L (150 IU/L) D. Alkaline phosphatase = 210 units/L (210 IU/L)

✅Answer: D Rationale: The laboratory values for the Choices A, B, and C are all within normal limits. However, the normal value of alkaline phosphatase is 30-120 units/L (40-160 IU/L) and the value is much higher than the normal range value. Chapter 44 - Assessment of the Musculoskeletal System iggy

The nurse is caring for a postoperative client with total hip arthroplasty. What actions would the nurse take to prevent venous thromboembolism (VTE) postoperatively? (Select all that apply.) Select all that apply. Apply pneumatic or sequential compression devices. Administer anticoagulant therapy. Ambulate the client on the day of surgery. Elevate the client's legs. Keep the legs slightly abducted.

✅Apply pneumatic or sequential compression devices. ✅Administer anticoagulant therapy. ✅Ambulate the client on the day of surgery. Preventive postoperative actions that help prevent VTE include pharmacology (anticoagulants), ambulation, and compression. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

The nurse recognizes that a client who has persistent pain may have difficulty with pain management after a total joint arthroplasty. What collaborative interventions are needed to help the client manage postoperative pain? (Select all that apply.) Select all that apply. Establish trust and explain the postoperative pain management plan. Consult the pain management team if needed and available. Plan continuing pain management after discharge. Use multimodal and alternative pain management modalities. Identify at-risk clients preoperatively using a comprehensive assessment.

✅CORRECT Establish trust and explain the postoperative pain management plan. All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain. CORRECT Consult the pain management team if needed and available. All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain. CORRECT Plan continuing pain management after discharge. All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain. CORRECT Use multimodal and alternative pain management modalities. All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain. CORRECT Identify at-risk clients preoperatively using a comprehensive assessment. All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

The nurse is caring for a client who has a continuous femoral nerve blockade following a total knee arthroplasty. What nursing assessment does the nurse need to perform to ensure client safety? Monitor vital signs frequently to detect early complications. Perform focused cardiovascular and respiratory assessments. Check that the client can dorsiflex and plantar flex the foot on the operative leg. Monitor for excessive blooding and bruising during the infusion.

✅Check that the client can dorsiflex and plantar flex the foot on the operative leg. To ensure that the client is not receiving excessive anesthesia, the client should be able to dorsiflex and plantar flex the foot on the operative leg. The purpose of the continuous femoral nerve blockade is to help control postoperative pain Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

The nurse assesses a client diagnosed with Sjögren syndrome. The nurse anticipates that the client will also have which symptom? Excessive production of saliva in the mouth Intermittent episodes of diarrhea Abdominal bloating after eating Dry eyes

✅Dry eyes Clients with Sjögren syndrome experience dry eyes (keratoconjunctivitis sicca), dry mouth, and if female, dry vagina. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

The nurse is caring for a client with osteoarthritis who reports severe pain in both knees. What nonpharmacologic intervention is the most appropriate for the nurse to recommend for this client? Massage and hypnosis. Hot compresses or moist heating pad. Glucosamine and chondroitin combination. Ice packs used every 3 to 4 hours during the day.

✅Glucosamine and chondroitin combination. Heat sources such as compresses and heating pads cause vasodilation which promotes healing in the affected joints. Ice is best for inflamed joints rather than those that are degenerative. Glucosamine and chondroitin are integrative therapies that help some clients but their effectiveness has not been validated. Massage would be painful and hypnosis may or may not be helpful, depending on the client. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

The nurse is caring for a client with an inflamed, reddened, and severely painful first metatarsal joint. With what type of arthritis are these signs and symptoms associated? Rheumatoid arthritis Infectious arthritis Gouty arthritis Osteoarthritis

✅Gouty arthritis Clients who have gout (also called gouty arthritis) experience severe inflammation in small joints, especially the metatarsal of the great (first) toe. Gout results when urate crystals created by errors in purine metabolism deposit in small synovial joints Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

10 of 11 The nurse is performing a focused musculoskeletal assessment on an older female client. What assessment findings associated with aging would the nurse expect? (Select all that apply.) Select all that apply. Scoliosis Kyphosis Decreased range of motion Muscle atrophy Osteoarthritis Widened gait

✅Kyphosis ✅Decreased range of motion ✅Muscle atrophy ✅Osteoarthritis ✅Widened gait All of these assessment findings are associated with aging, especially in women, except for scoliosis. Scoliosis is a lateral curvature of the spine that is usually diagnosed in children and adolescents Chapter 44 - Assessment of the Musculoskeletal System iggy

4 of 11 When assessing a female client, the nurse learns that the client has several risk factors for osteoporosis. Which risk factor would be the priority for client teaching? Low calcium intake Postmenopausal status Positive family history Previous use of steroids

✅Low calcium intake The client's calcium and vitamin D intake is the priority risk factor that the client can change. The nurse will discuss the other risk factors as contributing to osteoporosis, but the teaching will focus on ways to increase calcium intake. Postmenopausal status, positive family history, and previous use of steroids are not risk factors that the client can change. These risk factors should be discussed but are not the priority for this client. Chapter 44 - Assessment of the Musculoskeletal System iggy

Which aspect of postoperative management will the nurse plan to discuss with a client about to undergo an arthroscopic repair of the knee? Pharmacy for client medications Physical therapy for exercises Social work for care coordination Registered dietitian for nutrition

✅Physical therapy for exercises The nurse and the physical therapist will discuss postoperative physical therapy with the client and will assess and collaborate on the postoperative exercises which will be necessary to establish ROM after the procedure. It is the nurse's responsibility to assess which medications the client is currently taking. Nutritional assessment is performed by the nurse, but this might also involve a dietitian if special needs exist. Unless there are postoperative complications or if the client has a variety of special needs, care coordination is not necessary. Chapter 44 - Assessment of the Musculoskeletal System iggy