Ch 63: Musculoskeletal Problems

During a health screening event, which assessment finding would alert the nurse to the possible presence of osteoporosis? 1. A measurable loss of height 2. The presence of bowed legs 3. Poor appetite and aversion to dairy products 4. Development of unstable, wide-gait ambulation

1 A measurable loss of heightA gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis, in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis, but are not indicative of osteoporosis. A wide gait is used to support balance and does not indicate osteoporosis.

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. Treatment of the disease includes administration of calcium, vitamin D, calcitonin, and bisphosphonates. Additional recommendations would include creating a safe environment, using firm mattress, wearing a corset, and using appropriate body mechanics and assistive devices.

A patient with morbid obesity with a history of hyperlipidemia comes in to the clinic stating that he or she has muscular weakness in the pelvic region and difficulty walking. What laboratory findings does the nurse expect to see? 1. Calcium 7.0 mg/dL 2. Phosphorus 5.5 mg/dL 3. Alkaline phosphatase 12 U/L 4. 25-hydroxy vitamin D 80 ng/mL

1 A morbidly obese patient with a history of hyperlipidemia is at high risk for the development of osteomalacia, and muscular weakness in the pelvic region and difficulty walking are clinical manifestations of osteomalacia. Patients with osteomalacia have a decreased serum calcium level (125 U/L), and a decreased 25-hydroxyvitamin D level

A nurse provides preoperative teaching to a patient who is scheduled for a laminectomy. What should the nurse include when discussing what will be removed during the surgical procedure? 1. A portion of the involved vertebral lamina 2. he nerve root affected by the cord compression 3. The spinous processes of the vertebrae in the affected area 4. A major portion of the vertebrae involved in the area of herniation

1 A portion of the vertebral lamina is removed to reach the disk, explore the involved nerve root, and remove any disk fragments. In a laminectomy, the nerve root, vertebrae, and spinous process are not removed

The nurse is admitting a patient to the acute care unit with a history of a herniated lumbar disc and low back pain. In completing a more thorough pain assessment, the nurse should ask the patient if which action aggravates the pain? 1. Bending or lifting 2.Application of warm moist heat 3. Sleeping in a side-lying position 4.Sitting in a fully extended recliner

1 Bending or liftingBack pain that is related to a herniated lumbar disc often is aggravated by events and activities that increase the 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). Application of 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 exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu to prevent constipation? 1. Bran muffin 2. Scrambled eggs 3. Puffed rice cereal 4. Buttered white toast

1 Each meal should contain one or more sources of fiber, which will reduce the risk of constipation and straining with defecation, which increases back pain. Bran is typically a high-fiber food choice and is appropriate for selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber and will not prevent constipation as well as the bran will.

The nurse is caring for a patient in the postoperative phase of spinal surgery. What nursing action is most appropriate when turning a patient? 1. Placing a pillow between the patient's legs and turning the body as a unit. 2. Having the patient turn to the side by grasping the side rails to help turn over. 3. Elevating the head of bed 30 degrees and having the patient extend the legs while turning. 4. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed.

1 Placing a pillow between the legs and turning the patient as a unit log rolling helps to keep the spine in good alignment and reduces pain and discomfort following spinal surgery. Having the patient turn by grasping the side rail to help puts strain on the back. Turning with head of bed at 30 degrees with legs extended will misalign the spine and likely cause damage. Elevating the head of the bed and turning the head, shoulders, and hips separately will cause pain and misalign the spine.

Which sport injury interventions are considered independent nursing interventions? Select all that apply. 1. Elevate the extremity to prevent swelling. 2. Assess neurovascular status for the injury. 3. Apply ice to the injured area to decrease swelling. 4. Use compression for the first 24 to 48 hours (ACE wrap). 5. Do not move the victim until the condition of the spinal cord is ascertained.

1,2,3,5 The acronym RICE—rest, ice, compression, and elevation—refers to basic treatment plans for strains and sprains. Applying ice and elevating an injured extremity, along with assessing the neurovascular status, are all independent nursing interventions and should be done. In addition, the nurse has the knowledge and experience to know that a victim of injury should not be moved until it is determined that spinal cord injury has not occurred. Use of an ACE wrap is a collaborative intervention.

The client is in skeletal traction and has 10-pound (4.5-kg) weights prescribed. What interventions should the nurse implement in the care of this client? Select all that apply. 1. Check the ropes for knots or frayed ends. 2. Check that the weights are hanging freely. 3. Ensure the weights are resting on the bed to help move the client. 4. Inform the licensed practical nurse (LPN) of the prescribed weight amounts. 5. Inspect the skin at least every 24 hours for signs of irritation or inflammation.

1.2.4 For traction, all weights and ropes must hang freely and not be frayed or have knots in them. The weights are never to be placed on the bed. Informing the LPN of the prescribed weight is acceptable, but it is necessary to understand that it is the responsibility of the registered nurse (RN) to make sure the correct weight is on the traction. Inspecting the skin is critical to detect the possibility of osteomyelitis, but it should be inspected every 8 to 12 hours, not 24 hours.

A patient has impaired physical mobility related to low back pain due to a herniated lumbar disc. What are appropriate nursing interventions for this diagnosis? Select all that apply. 1. Sleep on a side-lying position. 2. Apply heat to the affected area. 3. Lean forward without bending at the knees. 4. Sleep on the abdomen or in a supine position. 5. Maintain a body mass index (BMI) of 18.5 to 24.9

1.2.5 The nurse should encourage the patient to maintain a healthy body weight, apply heat or ice to the painful area, and sleep in a side lying position to help alleviate pain and improve mobility. Sleeping on the abdomen will hyperextend the back and increase pain and decrease mobility. Bending should occur at the waist while bending the knees to support the lower back.

The nurse is caring for a client in skeletal traction. The nurse is assessing the pin sites and notes the presence of purulent drainage. Which nursing action would be most appropriate? 1. Document the findings. 2. Notify the primary health care provider. 3. Apply antibiotic ointment to the pin sites. 4. Clean the pin sites more frequently than prescribed

2 A small amount of clear fluid drainage (serous) is expected at pin insertion sites. Signs of infection, such as inflammation, purulent drainage, and pain at the pin sites are not expected findings and should be reported to the primary health care provider. Options 1, 3, and 4 are inappropriate nursing actions.

The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is most appropriate? 1. Contact the primary health care provider. 2. Petal the cast edges with adhesive tape. 3. Massage the skin at the edges of the cast. 4. Place a small facecloth in the cast around the edges of the cast.

2 If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. Massaging the skin will not eliminate the problem. Placing a small facecloth in the cast around the edges of the cast is not appropriate. It is not necessary to contact the primary health care provider.

The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg and notes the presence of edema in the foot below the cast. The nurse should interpret that this finding indicates which complication? 1. Arterial insufficiency 2. Impaired venous return 3. Impaired arterial circulation 4. The presence of an infection

2 Impaired venous returnEdema (swelling) in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast, or the presence of hot spots, which are areas of the cast that are warmer than others.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find when assessing the patient? 1. Nausea and vomiting 2. Localized pain and warmth 3. Paresthesia in the affected extremity 4. Generalized bone pain throughout the leg

2 Osteomyelitis is an infection of bone and bone marrow that can occur with trauma or surgery, or it can 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, vomiting, and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized, not generalized throughout the leg. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

The nurse is planning health promotion teaching for a patient with asthma, low back pain from a herniated lumbar disc, and paranoid schizophrenia. The nurse determines that what would be the best exercise to include in an individualized exercise plan for the patient? 1. Yoga 2. Walking 3. Calisthenics 4. Weight lifting

2 The patient would benefit from an aerobic exercise that takes into account 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. Yoga, calisthenics, and weight lifting would all put pressure on or strain the spine.

A patient is admitted to the nursing unit with a history of a herniated lumbar disc and lower-back pain. The nurse would suspect which causative factor of increasing pain? 1. Humid weather 2. Bending forward 3. Frequent position changes 4 Sleeping on a firm mattress

2. Bending forwardBack pain that is related to a herniated lumbar disc often is aggravated by events and activities that increase stress and strain on the spine, such as bending or lifting, coughing, sneezing, or lifting the leg with the knee straight (straight-leg-raise test). Sleeping on a firm mattress and frequent position changes are recommended to reduce pain, and warm weather will not increase pain.

The nurse is assessing a patient who is taking alendronate for osteoporosis. What should the nurse inform the patient to be aware of when taking this medication? 1. Helps replace low calcium levels 2. Can lead to uncontrolled weight gain 3. Must be taken with a full glass of water 4. Is always given after primary treatment with estrogen therapy

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The nurse witnesses a motor vehicle crash in which a pedestrian is hit by a car, and the nurse suspects that the client has a fractured leg. Which is the most appropriate nursing action? 1. Try to manually reduce the fracture. 2. Leave the victim to call an ambulance. 3. Stay with the victim, and encourage the victim to remain still. 4. Assist the victim to get up and walk to the sidewalk so that he is safe.

3 The client with a suspected fracture is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. A fracture is not reduced at the scene, and reduction is not performed by the nurse. The site of the fracture is immobilized to prevent further injury before moving the client.

Which individuals would be at high risk for low back pain (select all that apply)? a. A 63 yo man who is a long-distance truck driver b. A 36 yo construction worker who is 6'2" and weighs 260 lbs c. A 44 yo female chef with prior compression fracture of the spine d. A 30 yo nurse who works on an orthopedic unit and smokes e. A 28 yo female yoga instructor who is 5'6" and weighs 130 lbs

A, B, C, D Risk factors associated with low back pain include lack of muscle tone, excess body weight, stress, poor posture, cigarette smoking, pregnancy, prior spinal compression fractures, spinal problems since birth, and a family history of back pain. Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and prolonged sitting are also associated with low back pain. Low back pain is most often caused by a musculoskeletal problem. Causes of low back pain of musculoskeletal origin include (1) acute lumbosacral strain, (2) instability of the lumbosacral spine, (3) osteoarthritis of the lumbosacral vertebrae, (4) degenerative disc disease, and (5) herniated disc. 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 diagnosed with osteosarcoma of the humerus demonstrates understanding of his treatment options when he states: a. "I accept that I have to lose my arm 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'm 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. Limb-salvage procedures, including wide surgical resection of the tumor, thus can be used more often. Osteosarcoma is an extremely aggressive primary bone tumor that rapidly metastasizes to distant sites.

A patient who has had surgical correction of bilateral hallux valgus is being discharged from the same-day surgery unit. The nurse will instruct the patient to a. expect continued pain in the feet b. rest frequently with the feet elevated c. soak the feet in warm water several times a day d. expect the feet to be numb for the next few days

B After surgical correction of bilateral hallux valgus, the feet should be elevated with the heel off the bed to reduce discomfort and decrease edema.

The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus? a. 22-yr-old female patient with gonorrhea who is an IV drug user b. 48-yr-old male patient with muscular dystrophy and acute bronchitis c. 32-yr-old male patient with type 1 diabetes mellitus and stage IV pressure ulcer d. 68-yr-old female patient with hypertension who had a knee arthroplasty 3 years ago

C Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. 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.

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 will 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. Clinical manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Other manifestations include weakness, depressed reflexes, anorexia, bone pain, fractures, polyuria, dehydration, and nephrolithiasis. 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.

The client with multiple fractures who is at risk for compartment syndrome should also be assessed by the nurse for which additional disease process? 1. Hyperlipidemia 2. Cardiac disease 3. Myoglobinuric kidney failure 4. Chronic obstructive pulmonary disease (COPD)

3 When fractures and muscle breakdown occur, myoglobin is released and clogs up the renal tubules of the kidneys, causing kidney failure. The other disease processes are not risks for compartment syndrome in conjunction with multiple fractures.

A client seeks treatment for a fractured radius. There is an open wound on the arm, and jagged bone edges protrude through the wound. The nurse determines that the client has which type of fracture? 1. Open fracture 2. Simple fracture 3. Greenstick fracture 4. Comminuted fracture

1 An open fracture (compound fracture) is one in which the skin or mucous membrane has been broken and the wound extends to the depth of the fractured bone. A simple fracture is a fracture of the bone across its entire shaft, with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture that occurs through part of the cross-section of a bone; one side of the bone is fractured, and the other side is bent. A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments.

The client presents to the emergency department with an injured ankle from playing basketball. While the nurse waits on the transporter to take the client for radiology what will be the nurse's priority intervention? 1. Apply ice to the injury. 2. Splint the ankle with an air cast. 3. Administer morphine by intravenous push. 4. Administer a nonsteroidal anti-inflammatory drug orally.

1 Applying ice to an injury is a priority. Administering medication before ascertaining if the ankle is broken may mask some symptoms. Splinting with an air cast may further injure the ankle before the radiograph is taken.

Which client would most likely have functional urinary incontinence? 1. A client who is in skeletal traction 2. A client who has frequent bladder spasms 3. A client who has been diagnosed with pneumonia 4. A client diagnosed with benign hypertrophic prostate (BPH)

1 Functional incontinence occurs when a person is aware of the need to go to urinate or defecate, but one or more physical or mental reason is preventing him or her from getting to a toilet. The skeletal traction is the physical barrier contributing to the functional incontinence for the client in this question.

The nurse is assessing a patient for radicular pain related to a herniated lumbar disc. What assessment technique should the nurse perform to elicit the response for confirmation? 1. Straight leg raises 2. Anterior drawer test 3. Passive range of motion exercises 4. Costovertebral angle (CVA) tenderness

1 Straight leg raisesLower-back pain associated with herniated lumbar disc is accompanied by radiation along the sciatic nerve and commonly is described as traveling through the buttock, to the posterior thigh, or down the leg. This is because the herniated disc compresses spinal nerves as they exit the spinal column, causing pain during straight leg raises. The anterior drawer test is used to assess knee injury. Passive range of motion will not elicit assessment cues related to a herniated disc. CVA tenderness would indicate kidney inflammation.

The nurse is providing instructions to a client regarding the use of crutches and is demonstrating the method for going down the stairs with the crutches. The nurse should instruct the client to move the crutches in which manner? 1. Crutches and the affected leg down followed by the unaffected leg 2. Crutches and the unaffected leg down followed by the affected leg 3. Unaffected leg down first followed by the crutches and the affected leg 4. Affected leg down first followed by the crutches and the unaffected leg

1 Strong leg down followed by unaffected leg

The nurse is teaching a client experiencing a body image disturbance caused by an amputation on the right leg about residual limb (stump) care. The nurse determines that the client is making the best initial positive adaptation if the client takes which action? 1. Agrees to look at the residual limb 2. States that residual limb care is the nurse's job while in the hospital 3. Asks to wait 1 more day before beginning to learn residual limb care 4. Asks to have his wife, rather than himself, learn about residual limb care

1 The most positive initial step in learning to care for a residual limb and to accept it as a part of the self is to be able to look at the residual limb. Once the client is able to look at the residual limb and touch it, learning about care can proceed more successfully. Each of the other options indicates a deferral or refusal on the part of the client, which makes them less-than-optimal choices.

The nurse is performing pin care to the pin sites of a client in skeletal traction and notes the presence of serous drainage. The nurse should take which nursing action? 1. Document the findings. 2. Notify the primary health care provider. 3. Remove 2 pounds of weight from the traction. 4. Lift the weights and place them on the bed so that the primary health care provider can assess the client.

1 This is an expected finding. A small amount of serous oozing is expected at the pin insertion site. The nurse should document the findings. It is not necessary to notify the primary health care provider. The nurse should not add or remove any weight from the client's traction setup because this would disrupt the alignment of the fracture.

The nurse is assessing a patient with lower back pain. What prevention methods should the nurse teach the patient? Select all that apply. 1. Use a pillow for sitting. 2. Sleep in a prone position. 3. Bend at the knees when lifting heavy objects. 4. Consult health care provider about exercising. 5. Lift objects by holding them away from the body.

1.3.4 The nurse should teach the patient to support the back using a pillow or lumbar roll when sitting. The nurse should teach the patient to use proper body mechanics such as bending the knees when lifting heavy objects and holding them close to the body. The patient should never exercise without consulting the health care provider.

The nurse is compiling discharge instructions for a client who has just had a short arm plaster cast put on. What information should the nurse include in the instructions? Select all that apply. 1. Be sure to cover the cast with a covering to protect it if ice is applied. 2. Be sure to use a plastic-covered pillow for elevation to protect the pillow. 3. For the first 24 to 48 hours, handle the cast with the palms of your hands. 4. The cast should be flush against the skin with no room between the cast and skin. 5. Monitor for circulation problems and report numbness, tingling, or discoloration of the extremity.

1.3.5 A plaster cast should be covered with a protective covering to prevent it from getting wet if ice is used to decrease swelling. A plaster cast should be handled with the palms of the hands to prevent indentations and pressure on the skin until the plaster fully dries in 24 to 48 hours. Circulation is a concern for a cast; compartment syndrome must be prevented by decreasing swelling and numbness, and tingling is the first sign of compartment syndrome. A cast should not be too tight; one to two fingers should be inserted to check for the appropriate fit.

The nurse is preparing a presentation for seniors in independent living accommodations about the risk factors associated with hip fractures. Which topics should the nurse include in the presentation as potential risk factors? Select all that apply. 1. The physiological changes of aging 2. The type of clothes worn by seniors 3. Diminished visual acuity and hearing 4. The type of social activities participated in 5. The various disease processes (such as osteoporosis)

1.3.5 The physiological changes associated with aging, diminished visual acuity and hearing, and the various disease processes such as osteoporosis are all identified risk factors that seniors should be educated about. The types of clothes may be a factor in regard to the use of hands and arthritis, but not hip fractures. Social activities in general are not considered a risk for hip fractures.

The nurse is caring for a patient following lumbar fusion. What nursing interventions should the nurse perform for this patient? Select all that apply. 1. Assess extremity circulation. 2. Use a soft mattress for comfort. 3. Place patient in Fowler's position. 4. Monitor peripheral neurologic signs. 5. Report severe headache to the surgeon.

1.4.5 The nurse caring for the patient who had a lumbar fusion should assess extremity circulation using temperature, capillary refill, and pulses. The nurse must report to the surgeon the presence of severe headache, which could be due to leakage of cerebrospinal fluid (CFS). The nurse must monitor the patient's peripheral neurologic signs. The nurse should perform these assessments every two to four hours during the first 48 hours after surgery. The patient should be provided with a firm mattress or bed board. The patient should be placed in supine position with pillows under the thighs of each leg or in a side-lying position with pillows between the legs for comfort and alignment.

A patient with osteomyelitis asks the nurse how this problem will be treated first. What is the best response by the nurse? 1. "You will need oral antibiotics and antifungals for two to three months." 2. "Intravenous antibiotics are the first treatment choice for this condition." 3."It is likely that a portion of your bone will be removed to treat the infection." 4."Surgery to remove the damaged tissue is the best way to treat this condition

2 "Intravenous antibiotics are the first treatment choice for this condition."The standard treatment for osteomyelitis consists of several weeks of intravenous antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Oral antibiotics are not as effective as intravenous antibiotics for this severe infection. If the antibiotics fail to resolve the infection, surgery may be indicated; however, this is not the first line of treatment

A patient reports swelling of the bursa and the formation of a callus over a bony enlargement of the forefoot. Which disorder does the nurse determines correlates with these findings? 1.Hammertoe 2.Hallux valgus 3.Hallux rigidus 4. Morton's neuroma

2 A patient with Hallux valgus disorder, or a bunion, has a painful deformity of the great toe towards the second toe. Swelling of bursa and the formation of a callus over a bony enlargement are the common symptoms of a bunion. A Morton's neuroma is characterized by a neuroma developing in the web space between the third and fourth metatarsal heads. The neuroma causes sharp and sudden attacks of pain and a burning sensation in the patient. With hammertoe, the patient has difficulty walking or wearing shoes and pain and a burning sensation on the bottom of the foot. Hallux rigidus is associated with painful stiffness at the metatarsophalangeal joint.

The nurse provided discharge instructions to a client who has had an external fixator placed on the right wrist. Which statement, if made by the client, indicates a need for further teaching? 1. "I can still exercise my arm with the external fixator on it." 2. "Yellow/green drainage is expected in the first 48 to 72 hours after surgery." 3. "I will clean the pin sites according to the approved directions given to me." 4. "I will need to monitor the pin sites every 8 to 12 hours for drainage, color, odor, and severe redness."

2 Clear, serous drainage or oozing is expected from the pin sites in the first 48 to 72 hours after surgery. Yellow/green drainage is called purulent drainage and indicates an infection. Exercising the arm and cleaning the site are appropriate actions.

The patient has a prescription for gentamicin. The nurse would hold the dose and notify the health care provider if the patient developed which concern? 1. Fever 2. Tinnitus 3. Epistaxis 4. Constipation

2 Gentamicin is an aminoglycoside antibiotic that can cause ototoxicity and nephrotoxicity. For this reason, the nurse would notify the health care provider of tinnitus, because this may indicate that ototoxicity is developing. Fever would indicate infection, which is the reason the patient would be prescribed this medication. Constipation and epistaxis are unrelated to gentamicin use.

A patient receiving intravenous (IV) vancomycin needs to have a trough drug level drawn. The medication will infuse over 60 minutes and the next dose is due to be given at 1300. The nurse should obtain a blood sample at which time? 1. 1200 2. 1230 3. 1330 4.1400

2 The trough level indicates the lowest concentration of medication in the bloodstream between doses and therefore should be measured just before infusion of the next dose to be sure the patient is metabolizing and excreting the medication effectively. In this case, if the medication infuses at 1300, the sample should be drawn at 1230. 1200, 1330, and 1400 do not coincide with the proper time to evaluate the serum trough level.

To reduce the incidence of pain for a patient with low back pain, the nurse includes which interventions? Select all that apply. 1. Maintaining the patient on strict bed rest. 2. Applying heat or ice to the area of most pain. 3. Preventing the patient from lifting anything at the bedside. 4. Administering prescribed nonsteroidal antiinflammatory drugs (NSAIDs). 5. Placing a pillow between the patient's legs and turning the body as a unit

2.4.5 Placing a pillow between the legs and turning the patient as a unit helps to keep the spine in good alignment and reduces the pain of a herniated lumbar disc. Heat or ice and NSAIDs are recommended treatment for low back pain. Bed rest is not advised and the patient may lift items using proper body mechanics.

A patient is receiving alendronate for treatment of osteoporosis. The nurse should provide education after noting which action by the patient? 1. Takes the medication with 8 ounces of water 2. Increases intake of calcium and vitamin D 3. Takes the medication immediately before bed 4. Continues to perform weight-bearing exercises

3 A patient taking alendronate should remain in an upright position, not lie down and go to bed. Alendronate is indicated for the treatment of osteoporosis and should be taken with a full glass of water. The patient should then remain in an upright position for at least 30 minutes to reduce epigastric discomfort. Taking the medication with 8 ounces of water, increased intake of calcium and vitamin D, and weight-bearing exercises are all correct actions.

A patient with diabetes mellitus is diagnosed with osteomyelitis of the foot. What medication does the nurse anticipate administering to the patient? 1. Metformin 2. Exenatide 3. Tobramycin 4. Hydromorphone

3 Tobramycin is an aminoglycoside-type antibiotic that often is used to treat osteomyelitis. The medication is given by the intravenous route for several weeks, and blood levels are checked periodically to ensure that they are therapeutic. Exenatide and metformin are used to treat diabetes, and hydromorphone is used to manage pain.

Buck's traction will be applied to the right leg of a client who sustained a right hip fracture. The nurse creates a plan of care for the client and should include which intervention in the plan? 1. Apply lanolin to the skin before applying the traction. 2. Remove the traction weights once every 2 hours for 15 minutes. 3. Check the skin integrity of the right leg at least every 2 to 4 hours. 4. Clean the pin sites with half-strength hydrogen peroxide once per shift.

3 Buck's traction is a type of skin traction. It is important with skin traction to inspect the skin underneath at least every 2 to 4 hours for irritation or inflammation. Applying lanolin to the skin could make the skin area slippery, making it difficult to maintain the belt or boot used for the skin traction. The nurse never releases the weights of traction unless specifically prescribed by the primary health care provider. There are no pins to care for with skin traction.

The nurse is providing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse should tell the client that which food item provides the least amount of calcium? 1. Milk 2. Cheese 3. Hamburger 4. Plain yogurt

3 Foods high in calcium include plain yogurt, dairy products, seafood, sardines, green vegetables, calcium-fortified orange juice, and cereal. Of the items listed, option 3 contains the least amount of calcium.

The nurse is caring for an older patient with primary osteosarcoma of the distal femur. What does the nurse recognize about this diagnosis? 1. Metastasis occurs in over 50% of individuals 2. Chemotherapy is contraindicated preoperatively 3. This malignancy often is associated with prior radiation 4. This is a rare form of cancer in children and young adults

3 In the older patient, osteosarcoma is often associated with Paget's disease and prior radiation. After diagnosis, metastasis only occurs in about 10 percent to 20 percent of individuals. Chemotherapy is often given preoperatively to reduce the tumor size before surgery. Osteosarcoma is the most common cancerous bone tumor in children and young adults.

The nurse is admitting a patient who has a new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc and lower back pain from other causes, what would be the best question for the nurse to ask the patient? 1. "Is the pain worse in the morning or in the evening?" 2. "Is the pain sharp or stabbing, or burning or aching?" 3. "Does the pain radiate down the buttock or into the leg?" 4. "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?"

3 Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve and commonly can be 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 are important, but they do not elicit differentiating data.

A nurse is caring for a patient with a ruptured lumbar disk. What is the optimal position for the nurse to place patient? 1. Lying on the back with a small pillow 2. Lying on the abdomen with no pillow 3.Lying on the side with the legs flexed 4. Lying on the side with the legs straight

3 Lying on the side with the legs flexed is the most comfortable and therapeutic position for a patient with a ruptured, or herniated, disk. This position lessens muscular stress and tension on the injured area and can help promote healing. Lying on the back with a small pillow, lying on the abdomen with no pillow, and lying on the side with the legs straight are not recommended and may increase muscle strain in the lumbar area.

A patient hospitalized with osteomyelitis has a prescription for bed rest with bathroom privileges, with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? 1. Ambulate the patient to the bathroom every two hours. 2. Ask the patient about preferred activities to relieve boredom. 3. Perform frequent position changes and range-of-motion exercises. 4. Allow the patient to dangle legs at the bedside every two to four hours.

3 Perform frequent position changes and range-of-motion exercises.The patient is at risk for atelectasis of the lungs and for 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 (ROM) exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe, because the patient is in pain, but it may not be needed every two hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest, and dangling the legs every two to four hours may be too painful. The priority is position changes and ROM exercises.

The nurse determines that dietary teaching for a patient with osteoporosis has been successful when the patient selects which highest calcium meal? 1. Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice 2. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple 3.A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk 4. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

3 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 emergency department nurse prepares to care for a client with a suspected fracture of the right radial bone. The nurse should initially implement which action? 1. Obtain an x-ray of the right arm. 2. Place a plastic cast on the right arm. 3. Check for distal pulses and the neurovascular status of the right arm. 4. Place the right arm in a sling, and arrange for an orthopedic consultation.

3 The initial intervention is to check for distal pulses and the neurovascular status of the affected extremity. A primary health care provider is responsible for obtaining an x-ray and applying a cast. It may be appropriate to place the extremity in a sling, but this is not the initial action.

The nurse is planning health promotion teaching for a patient with asthma, low back pain from a herniated lumbar disc, and hypertension. The nurse determines which exercise would be best to include in an individualized exercise plan for the patient? 1. Tennis 2. Running 3. Walking 4. Weightlifting

3 The patient would benefit from an aerobic exercise that takes into account the patient's health status and fits the patient's lifestyle. The best exercise of those listed is walking, which builds strength in the back and leg muscles and is an aerobic exercise as well. Running, weightlifting, and tennis may result in improper body mechanics, too much stress on the body, and increased low back pain. Running also may result in asthma exacerbation.

A patient with a tumor in the left leg states there is severe pain at the site of the tumor. The patient states, "Why is there so much pain?" What is the best response by the nurse? 1. "This is a side effect of radiation therapy." 2. "The pain medication must not be working." 3. "The tumor may be pressing on nerves near the bone."

3 When the tumor presses on nerves or other organs, it causes severe pain. The question does not discuss any medications or doses that would be given for pain. Radiation therapy actually is used to help decrease the pain. Exercising will actually help decrease the pain as well.

The nurse has reviewed proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. Which statement made by the patient indicates a need for further teaching? 1. "I should sleep on my side or back with my hips and knees bent." 2. "I should exercise at least 15 minutes every morning and evening." 3. "I should pick up items by leaning forward without bending my knees." 4. "I should try to keep one foot on a stool whenever I have to stand for a period of time."

3. "I should pick up items by leaning forward without bending my knees."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 when 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. Exercising 15 minutes twice daily will be done once symptoms subside, and will be aimed at back-strengthening.

A client complained of phantom limb pain (PLP) the day after surgery for an above knee amputation (AKA). The client says, "I've never felt any pain like this before. It is killing me!" What is the nurse's most appropriate therapeutic reply? 1. "The pain is not real, so we don't treat it." 2. "You are having PLP, and it is not real." 3. "Don't worry; the pain will go away in a few days or so." 4. "Can you describe your pain, so it can be appropriately treated?

4 Asking the client to describe the PLP acknowledges that the pain is real for the client, and how it is described will determine how it is treated. Telling the client that the pain is not real is a nontherapeutic response. Telling the client not to worry is a false, pacifying statement and does not acknowledge the client's concern.

The nurse provides instructions to a pregnant woman in the second trimester regarding measures to relieve backache. Which statement by the client indicates an understanding of these measures? 1. "I will sleep on a soft mattress." 2. "I will avoid doing those pelvic tilt exercises." 3. "I will wear shoes with a heel of at least 2 inches (5 cm)." 4. "I will avoid getting tired, and I should work at maintaining a good posture."

4 Backache can occur because of the exaggerated lumbar and cervicothoracic curves caused by the change in the center of gravity with the enlarging abdomen. The client should be instructed to sleep on a firm mattress, to avoid becoming fatigued, and to maintain good posture and body mechanics. Pelvic tilt exercises decrease strain to muscles of the abdomen and lower back caused by the added weight of the abdomen and the shift in the center of gravity. Wearing high-heeled shoes will add to the strain on the muscles and will exaggerate the shift in the center of gravity

The nurse is caring for a client admitted to the hospital with a musculoskeletal injury. The nurse monitors for the major symptom associated with neurovascular compromise by implementing which intervention? 1. Counting the client's apical pulse for 1 full minute 2. Taking the client's blood pressure on the unaffected side 3. Observing for drainage on the dressing of the affected extremity 4. Determining if pain is experienced with passive motion of the affected extremity

4 Neurovascular compromise in a client with a musculoskeletal injury is created by increased pressure within a compartment. The pressure occurs because fascia is unable to expand when muscle swelling occurs. The only option that addresses neurovascular compromise is option 4.

A patient is admitted with cellulitis and osteomyelitis. The nurse concludes that there is significant inflammation through which laboratory finding? 1.Red blood cell count 4.5 2.Blood urea nitrogen (BUN) 24 3.White blood cell count 9500/mm3 4.Erythrocyte sedimentation rate (ESR) 88

4 The ESR is indicative of inflammation and typically is elevated in patients with osteomyelitis. The BUN, white blood cell count, and red blood cell count are normal and do not represent inflammation.

The nurse is caring for a patient who is prescribed a muscle relaxant for acute low back pain. What should the nurse teach the patient about managing low back problems? 1.Sleep in prone position. 2.Maintain complete bed rest. 3. Use a soft comfortable mattress. 4. Place a foot on a stool during prolonged standing.

4 The nurse should tell the patient to place a foot on a stool during prolonged standing to avoid straining the lower back. The patient should avoid complete bed rest; it is better for the patient to continue daily activities. The patient should be asked to sleep in supine or side-lying positions with knees and hips flexed to prevent unnecessary pressure on support muscles, ligaments, and lumbosacral joints. A firm mattress or a bed board is recommended instead of a soft mattress. Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way.

The nurse is reinforcing health teaching about osteoporosis with a patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? 1. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. 2. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. 3. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. 4. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

4 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. Even if the patient has a family history of osteoporosis, there are methods to prevent and slow bone resorption. Corticosteroids interfere with bone metabolism and would not be effective. Estrogen therapy is no longer used to prevent osteoporosis, because of the associated increased risk of heart disease and breast and uterine cancer.

What is 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 instructed to quit smoking in order to decrease bone loss.

The nurse provides instructions to a 30-yr-old female office worker who has low back pain. Which statement indicates 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 a spinal fusion, the nurse would immediately report which of the following to the surgeon? a. The patient experiences a single episode of emesis b. the patient is unable to move the lower extremities c. the patient is nauseated and has not voided in 4 hours d. the patient complains 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. Paresthesia, such as numbness and tingling, may not be relieved immediately after surgery. The nurse should immediately report any new muscle weakness or paresthesia to the surgeon and document this in the patient's medical record.

The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-yr-old patient who has low back pain from a herniated lumbar disc. 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 firmly 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.

A patient with osteomyelitis undergoes surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply): a. "Oral or IV antibiotics are not effective in most cases of bone infection." b. "The beads are an adjunct to debridement and antibiotics for deep infections." c. "The beads are used to deliver antibiotics directly to the site of the infection." d. "This Is the safest method to deliver long-term antibiotic therapy 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.

The nurse receives report from the licensed practical nurse 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 complaining of 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 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 will 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.

A patient with suspected disc herniation is experiencing 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 compresses 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 [Flexeril]). Massage and back manipulation, acupuncture, and application of cold and hot compresses may help some patients. Severe pain may require a brief course of opioid analgesics. 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 aggravate the pain, including lifting, bending, twisting, and prolonged sitting.

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.