Chapter 36 Management of Patients with Musculoskeletal Disorders

An older adult woman's current medication regimen includes alendronate. What outcome would indicate successful therapy? A. Increased bone mass B. Resolution of infection C. Relief of bone pain D. Absence of tumor spread

ANS: A Rationale: Bisphosphonates such as alendronate increase bone mass and decrease bone loss by inhibiting osteoclast function. These drugs do not treat infection, pain, or tumors.

An older, female client with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication of osteoporosis? A. Bone fracture B. Loss of estrogen C. Negative calcium balance D. Dowager hump

ANS: A Rationale: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause, not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance is not a complication of osteoporosis. Dowager hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

A nurse is assessing a client who reports a throbbing, burning sensation in the right foot. The client states that the pain is worst during the day but notes that the pain is relieved with rest. The nurse should recognize the signs and symptoms of what health problem? A. Morton neuroma B. Pes cavus C. Hallux valgus D. Onychocryptosis

ANS: A Rationale: Morton neuroma is a swelling of the third (lateral) branch of the median plantar nerve, which causes a throbbing, burning pain, usually relieved with rest. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Hallux valgus (bunion) is a deformity in which the great toe deviates laterally and there is a marked prominence of the medial aspect of the first metatarsal-phalangeal joint and exostosis. Onychocryptosis (ingrown toenail) occurs when the free edge of anail plate penetrates the surrounding skin, laterally or anteriorly.

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem? A. Osteomyelitis B. Osteoporosis C. Osteomalacia D. Septic arthritis

ANS: A Rationale: When osteomyelitis develops from the spread of an adjacent infection, no signs of septicemia are present, but the area becomes swollen, warm, painful, and tender to touch. Osteoporosis is noninfectious. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Septic arthritis occurs when joints become infected through spread of infection from other parts of the body (hematogenous spread) or directly through trauma or surgical instrumentation.

A nurse is providing care for a client who has a recent diagnosis of Paget disease.When planning this client's nursing care, what should interventions address? Select all that apply. A. Impaired physical mobility B. Acute pain C. Disturbed auditory sensory perception D. Risk for injury E. Risk for unstable blood glucose

ANS: A, B, C, D Rationale: Clients with Paget disease are at risk for decreased mobility, pain, hearing loss, and injuries resulting from decreased bone density. Paget disease does not affect blood glucose levels.

A nurse is caring for a client who is being assessed following reports of severe andpersistent low back pain. The client is scheduled for diagnostic testing in the morning.Which of the following are appropriate diagnostic tests for assessing low back pain?Select all that apply. A. Computed tomography (CT) B. Angiography C. Magnetic resonance imaging (MRI) D. Ultrasound E. X-ray

ANS: A, C, D, E

A client has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. Which of the following nursing diagnoses must be addressed in the plan of care? A. Risk for aspiration related to vertebral fracture B. Constipation related to vertebral fracture C. Impaired swallowing related to vertebral fracture D. Decreased cardiac output related to vertebral fracture

ANS: B Rationale: Constipation is a problem related to immobility and medications used to treat vertebral fractures. The client's risks of aspiration, dysphagia, and decreased cardiac output are not necessarily heightened.

A nurse is caring for a client who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention? A. Maintenance of high Fowler positioning whenever possible B. Intermittent application of heat to the client's back C. Use of a pressure-reducing mattress D. Passive range of motion exercises

ANS: B Rationale: Intermittent local heat and back rubs promote muscle relaxation following osteoporotic vertebral fractures. High Fowler positioning is likely to exacerbate pain. The mattress must be adequately supportive, but pressure reduction is not necessarily required. Passive range of motion exercises to the back would cause pain and impair healing.

A nurse is caring for a client with a bone tumor. The nurse is providing education to help the client reduce the risk for pathologic fractures. What should the nurse teach the client? A. Strive to achieve maximum weight-bearing capabilities. B. Gradually strengthen the affected muscles through weight training. C. Support the affected extremity with external supports such as splints. D. Limit reliance on assistive devices in order to build strength.

ANS: C

A client presents at a clinic reporting back pain that goes all the way down the backof the leg to the foot. The nurse should document the presence of what type of pain? A. Bursitis B. Radiculopathy C. Sciatica D. Tendonitis

ANS: C Rationale: Sciatica nerve pain travels down the back of the thigh to the foot of the affected leg. Bursitis is inflammation of a fluid-filled sac in a joint. Radiculopathy is disease of a nerve root. Tendonitis is inflammation of muscle tendons.

A client presents at the clinic with a report of morning numbness, cramping, and stiffness in the fourth and fifth fingers of the right hand. What disease process should the nurse suspect? A. Tendonitis B. A ganglion C. Carpal tunnel syndrome D. Dupuytren disease

ANS: D Rationale: In cases of Dupuytren disease, the client may experience dull, achingdiscomfort, morning numbness, cramping, and stiffness in the affected fingers.

A client tells the nurse that they haves pain and numbness in the thumb, first finger, and second finger of the right hand. The nurse discovers that the client is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the client has what health problem? A. Carpel tunnel syndrome B. Tendonitis C. Impingement syndrome D. Dupuytren contracture

Ans: A

A client's electronic health record notes that the client has hallux valgus. What signsand symptoms should the nurse expect this client to manifest?A. Deviation of a great toe laterally B. Abnormal flexion of the great toe C. An exaggerated arch of the foot D. Fusion of the toe joints

Ans: A

A nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize? A. The client will express satisfaction with the ability to perform ADLs. B. The client will recover from OA within 6 months. C. The client will adhere to the prescribed plan of care. D. The client will deny signs or symptoms of OA.

Ans: A

A nurse is caring for an adult client diagnosed with a back strain. What health education should the nurse provide to this client? A. Avoid lifting more than one-third of body weight without assistance. B. Focus on using back muscles efficiently when lifting heavy objects. C. Lift objects while holding the object a safe distance from the body. D. Tighten the abdominal muscles and lock the knees when lifting an object.

Ans: A

A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client? A. Stress on the weakened bone must be avoided. B. Increased heart rate enhances perfusion and bone healing. C. Bed rest results in improved outcomes in clients with osteomyelitis. D. Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.

Ans: A

A nurse is providing discharge teaching for a client who underwent foot surgery. The nurse is collaborating with the occupational therapist and discussing the use of assistive devices. On what variables does the choice of assistive devices primarily depend? A. Client's general condition, balance, and weight-bearing prescription B. Client's general condition, strength, and gender C. Client's motivation, age, and weight-bearing prescription D. Client's occupation, motivation, and age

Ans: A

The nurse is educating a client with low back pain on proper lifting techniques. The nurse recognizes that the education was effective when the client a. places the load close to the body. b. reaches over the head with the arms fully extended. c. uses a narrow base of support. d. bends at the hips and tightens the abdominal muscles.

Ans: A Instructions for the client with low back pain should include that, when lifting, the client should avoid overreaching. The client should also keep the load close to the body, bend the knees, and tighten the abdominal muscles; use a wide base of support; and use a back brace to protect the back. Bending at the hips increases the strain on the back muscles when lifting.

A nurse is caring for a client who is 12 hours' postoperative following foot surgery.The nurse assesses the presence of edema in the foot. What nursing measure should the nurse implement to control the edema? A. Elevate the foot on several pillows. B. Apply warm compresses intermittently to the surgical area. C. Administer a loop diuretic as prescribed. D. Increase circulation through frequent ambulation.

Ans: A Intermittent ice packs should be applied to the surgical area during the first 24 to 48hours after surgery to control edema and provide some pain relief. Ambulation willgradually be resumed based on the guidelines provided by the surgeon.

A nurse is teaching a client with osteomalacia about the role of diet. What would be the best choice for breakfast for a client with osteomalacia? A. Cereal with milk, a scrambled egg, and grapefruit B. Poached eggs with sausage and toast C. Waffles with fresh strawberries and powdered sugar D. A bagel topped with butter and jam with a side dish of grapes

Ans: A Rationale: The best meal option is the one that contains the highest dietary sources of calcium and vitamin D. The best selection among those listed is cereal with milk, and eggs, as these foods contain calcium and vitamin D in a higher quantity over the other menu options.

A patient is diagnosed with osteogenic sarcoma. What laboratory studies should the nurse monitor for the presence of elevation? a. Alkaline phosphatase b. Potassium level c. Magnesium level d. Troponin levels

Ans: A Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma or bone metastasis. Hypercalcemia is also present with bone metastases from breast, lung, or kidney cancer. Symptoms of hypercalcemia include muscle weakness, fatigue, anorexia, nausea, vomiting, polyuria, cardiac dysrhythmias, seizures, and coma. Hypercalcemia must be identified and treated promptly.

Identify descriptors of the pathophysiologic process seen in osteomalacia. Select all that apply. a. Calcium and phosphate are not moved to the bones. b. Excessive osteoclastic activity causes the bones to become soft and bowed initially; later, the bones thicken but are not well formed, making the bones weak and prone to fracture. c. The bone mass is structurally weaker, and bone deformities occur. d. There is a deficiency of activated vitamin D (calcitriol).

Ans: A, C, D

A client has come to the clinic for a routine annual physical. The nurse practitioner notes a palpable, painless projection of bone at the client's shoulder. The projection appears to be at the distal end of the humerus. The nurse should suspect the presence of: A. osteomyelitis. B. osteochondroma. C. osteomalacia. D. Paget disease.

Ans: B

A nurse is assessing a client for risk factors known to contribute to osteoarthritis.What assessment finding should the nurse interpret as a risk factor? A. The client has a 30 pack-year smoking history. B. The client's body mass index is 34 (obese). C. The client has primary hypertension. D. The client is 58 years old.

Ans: B

A nurse is caring for a client following foot surgery. Which nursing intervention is most important for the nurse to include in the nursing care plan? a. Administer pain medication per client request. b. Perform neuromuscular assessment every hour. c. Examine the surgical dressing every hour. d. Monitor vital signs every 4 hours.

Ans: B

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis? A. A middle-aged adult who takes ibuprofen daily for rheumatoid arthritis B. An older adult client with an infected pressure ulcer in the sacral area C. A 17-year-old football player who had orthopedic surgery 6 weeks prior D. An infant diagnosed with jaundice

Ans: B Rationale: Clients who are at high risk of osteomyelitis include those who are poorly nourished, older adults, and clients who are obese. The older adult client with an infected sacral pressure ulcer is at the greatest risk for the development of osteomyelitis, as this client has two risk factors: age and the presence of a soft-tissue infection that has the potential to extend into the bone. The client with rheumatoid arthritis has one risk factor and the infant with jaundice has no identifiable risk factors. The client 6 weeks 'post surgery is beyond the usual window of time for the development of a postoperative surgical wound infection.

A client has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery? A. Deficient fluid volume B. Delayed wound healing C. Hypocalcemia D. Pathologic fractures

Ans: B Rationale: Delayed wound healing is a complication of surgery due to tissue trauma from the surgery. Nutritional deficiency is usually due to the effects of chemotherapy and radiation therapy, which may cause weight loss. Pathologic fractures are not a complication of surgery.

A client presents at a clinic reports heel pain that impairs walking ability. The client is subsequently diagnosed with plantar fasciitis. This client's plan of care should include what intervention? A. Wrapping the affected area in lamb's wool or gauze to relieve pressure B. Gently stretching the foot and the Achilles tendon C. Wearing open-toed shoes at all times D. Applying topical analgesic ointment to plantar surface each morning

Ans: B Rationale: Plantar fasciitis leads to pain that is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon. Dressings of any kind are not of therapeutic benefit and analgesic ointments do not address the pathology of the problem. Open-toed shoes are of no particular benefit.

A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening? a. Trigeminal neuralgia b. Temporomandibular disorder c. Loose teeth d. Dislocated jaw

Ans: B The disorder can be confused with trigeminal neuralgia and migraine headaches. The client experiences clicking of the jaw when moving the joint, or the jaw can lock, which interferes with opening the mouth. Loose teeth will not cause a clicking of the jaw. The client does not have a dislocated jaw.

A nurse is discussing conservative management of tendonitis with a client. What is the nurse's best recommendation? A. Weight reduction B. Use of oral opioid analgesics C. Intermittent application of ice and heat D. Passive range of motion exercises

Ans: C

A nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching? a. "You need to limit the amount of protein and calcium in your diet." b. "Use your continuous passive motion machine for 2 hours each day." c. "You will receive IV antibiotics for 3 to 6 weeks." d. "You need to perform weight-bearing exercises twice a week."

Ans: C

A nursing educator is reviewing the risk factors for osteoporosis with a group ofrecent graduates. What of the following risk factors should the educator describe? A. Recurrent infections and prolonged use of NSAIDs B. High alcohol intake and low body mass index C. Small frame and female sex D. Male sex, diabetes, and high protein intake

Ans: C

Assessment of a client reveals signs and symptoms of Paget's disease. Which of the following would be most likely? a. Lordosis b. Skull narrowing c. Long bone bowing d. Upright gait

Ans: C

The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response? a. Decrease in parathyroid hormone b. Increase in calcitonin c. Decrease in estrogen d. Increase of vitamin D

Ans: C Age related processes that contribute to loss of bone mass and osteoporosis are decreases in estrogen, calcitonin, and vitamin D and an increase in parathyroid hormone.

The client with osteoarthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care? a. Reports ability to perform ADLs b. Reports decreased joint pain c. Has a weight gain of 5 pounds d. Shows increased joint flexibility

Ans: C Obesity is a risk factor for osteoarthritis. Excess weight is a stressor on the weight-bearing joints. Weight reduction is often a part of the therapeutic regimen.

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation? A. Estrogen B. Parathyroid hormone (PTH) C. Calcitonin D. Progesterone

Ans: C Rationale: Calcitonin inhibits bone resorption and promotes bone formation, estrogen inhibits bone breakdown, and parathyroid increases bone resorption. Estrogen, which inhibits bone breakdown, decreases with aging. Parathyroid hormone (PTH) increases with aging, increasing bone turnover and resorption. Progesterone is the major naturallyoccurring human progestogen and plays a role in the female menstrual cycle.

A nurse is caring for a client with Paget disease and is reviewing the client's most recent laboratory values. Which of the following values are most characteristic of Paget disease? A. An elevated level of parathyroid hormone and low calcitonin levels B. A low serum alkaline phosphatase level and a low serum calcium level C. An elevated serum alkaline phosphatase level and a normal serum calcium level D. An elevated calcitonin level and low levels of parathyroid hormone

Ans: C Rationale: Clients with Paget disease have normal blood calcium levels. Elevated serum alkaline phosphatase concentration and urinary hydroxyproline excretion reflect the increased osteoblastic activity associated with this condition. Alterations in PTH and calcitonin levels are atypical.

A client is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results are most suggestive of this diagnosis? A. High chloride, calcium, and magnesium levels B. High parathyroid and calcitonin levels C. Low serum calcium and magnesium levels D. Low serum calcium and low phosphorus level

Ans: D

A nurse is reviewing the care of a client who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug? A. Calcitonin B. Prednisone C. Aspirin D. Cyclobenzaprine

Ans: D

The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided? a. "I will bend at the waist when I am lifting objects from the floor." b. "Instead of turning around to grasp an object, I will twist at the waist." c. "I will lie prone with my legs slightly elevated." d. "I will avoid prolonged sitting or walking."

Ans: D

What term refers to a flexion deformity caused by a slowly progressive contracture of the palmar fascia? a. Hammertoe b. Callus c. Hallux valgus d. Dupuytren contracture

Ans: D Dupuytren disease results in a slowly progressive contracture of the palmar fascia, called Dupuytren contracture. A callus is a discretely thickened area of skin that has been exposed to persistent pressure or friction. A hammertoe is a flexion deformity of the interphalangeal joint, which may involve several toes. Hallux valgus is a deformity in which the great toe deviates laterally.

A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate? A. High levels of vitamin D can cause osteoporosis. B. A nonmodifiable risk factor for osteoporosis is a person's level of activity. C. Secondary osteoporosis occurs in women after menopause. D. The use of corticosteroids increases the risk of osteoporosis.

Ans: D Rationale: Corticosteroid therapy is a secondary cause of osteoporosis when taken forlong-term use. Adequate levels of vitamin D are needed for absorption of calcium.

The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action? a. Increase fiber in the diet b. Decrease the intake of vitamin A and D c. Reduce stress d. Walk or perform weight-bearing exercises outdoors

Ans: D Risk-lowering strategies for osteoporosis include walking or exercising outdoors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine in moderation.