Med Surg 411 Musculoskeletal (Lippincott)

Which of the following should be included in the teaching plan for a client with osteoporosis? Select all that apply. 1. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals. 2. Choose good calcium sources, such as figs, broccoli, and almonds. 3. Use alcohol in moderation because a moderate intake has no known negative effects. 4. Try swimming as a good exercise to maintain bone mass. 5. Avoid the use of high-fat foods, such as avocados, salad dressings, and fried foods.

1, 2, 3. A diet with adequate amounts of vitamin D aids in the regulation, absorption, and subsequent utilization of calcium and phosphorus, which are necessary for the normal calcification of bone. Figs, broccoli, and almonds are very good sources of calcium. Moderate intake of alcohol has no known negative effects on bone density but excessive alcohol intake does reduce bone density. Swimming, biking, and other non-weight-bearing exercises do not maintain bone mass. Walking and running, which are weight-bearing exercises, do maintain bone mass. The client should eat a balanced diet but does not need to avoid the use of high-fat foods.

Which of the following statements should the nurse include in the teaching session when preparing a client for arthrocentesis? Select all that apply. 1. "A local anesthetic agent may be injected into the joint site for your comfort." 2. "A syringe and needle will be used to withdraw fluid from your joint." 3. "The procedure, although not painful, will provide immediate relief." 4. "We'll want you to keep your joint active after the procedure to increase blood flow." 5. "You will need to wear a compression bandage for several days after the procedure."

1, 2, 5. An arthrocentesis is performed to aspirate excess synovial fluid, pus, or blood from a joint cavity to relieve pain or to diagnosis inflammatory diseases such as rheumatoid arthritis. A local agent may be used to decrease the pain of the needle insertion through the skin and into the joint cavity. Aspiration of the fluid into the syringe can be very painful because of the size and inflammation of the joint. Usually a steroid medication is injected locally to alleviate the inflammation; a compression bandage is applied to help decrease swelling; and the client is asked to rest the joint for up to 24 hours afterward to help relieve the pain and promote rest to the inflamed joint. The client may experience pain during this time until the inflammation begins to resolve and swelling decreases.

Which information should the nurse include when performing discharge teaching with a client who had an anterolateral approach for a total hip replacement? Select all that apply. 1. Avoid turning the toes or knee outward. 2. Use an abduction pillow between the legs when in bed. 3. Use an elevated toilet seat and shower chair. 4. Do not extend the operative leg backwards. 5. Restrict motion for 2 weeks after surgery

1, 3, 4. A client who has had a total hip replacement via an anterolateral approach has almost the opposite precautions as those for a client who has had a total hip replacement through the posterolateral approach. The hip joint should not be actively abducted. The client should avoid turning the toes or knee outward. The client should keep the legs side by side without a pillow or wedge. The client should use an elevated toilet seat and shower chair and should not extend the operative leg backward. The client should perform range-of-motion exercises as directed by the physical therapist

A client returns from the first session of scheduled physical therapy sessions following total knee replacement surgery. The nurse assesses that the client's knee is swollen, slightly erythematous, and painful. The client rates the pain as 7 out of 10 and has not had any scheduled or PRN pain medication today. Which of the following are appropriate nursing interventions? Select all that apply. 1. Gently massage the area to increase circulation to reduce pain. 2. Administer pain medication as prescribed. 3. Elevate the leg and apply a cold pack. 4. Notify the physician. 5. Call physical therapy to cancel the next treatment

2, 3. It is anticipated that there might be some swelling, redness, and discomfort immediately after activity, including physical therapy. Ideally, pain medication could be offered or given prior to therapy to reduce posttreatment pain, but should be administered now. Elevation and cold packs can also reduce swelling and decrease pain. It is not appropriate to notify the physician as pain and swelling are normal after therapy. It is also not appropriate to massage the area. This will increase circulation and therefore increase swelling and pain

After teaching a group of clients with osteoarthritis about using regular exercise, which of the following client statements indicates effective teaching?. 1. "Performing range-of-motion exercises will increase my joint mobility." 2. "Exercise helps to drive synovial fluid through the cartilage." 3. "Joint swelling should determine when to stop exercising." 4. "Exercising in the outdoors year-round promotes joint relaxation."

2. Weight-bearing exercise plays a very important role in stimulating regeneration of cartilage, which lacks blood vessels, by driving synovial fluid through the joint cartilage. Joint mobility is increased by weight-bearing exercises, not range-of-motion exercises, because surrounding muscles, ligaments, and tendons are strengthened. Pain is an early sign of degenerative joint bone problems. Swelling may not occur for some time after pain, if at all. Osteoarthritic pain is worsened in cold, damp weather; therefore, exercising outdoors is not recommended year round in all settings.

A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should:. 1. Elevate the stump. 2. Reinforce the dressing. 3. Call the surgeon. 4. Draw a mark around the site

4. DRAW A MARK AROUND THE SITE The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin. Once the rate and source of bleeding are identified, the surgeon should be notified. The stump is not elevated because adhesions may occur, interfering with the ability to fit a prosthesis. The dressing would be reinforced if the bleeding is determined to be of venous origin, characterized by slow oozing of darker blood that ceases with the application of a pressure dressing. Typically, operative dressings are not changed for 24 hours. Therefore, the dressing is reinforced to prevent organisms from penetrating through the blood-soaked areas of the initial postoperative dressing.

A client who had a total hip replacement 2 days ago has developed an infection with a fever and profuse diaphoresis. The nurse establishes a goal to reduce the fluid deficit. Which of the following is the most appropriate outcome?. 1. The client drinks 2,000 mL of fluid per day. 2. The client understands how to manage the incision. 3. The client's bed linens are changed as needed. 4. The client's skin remains cool throughout hospitalization.

1. An average adult requires approximately 1,100 to 1,400 mL of fluids per day. In some instances, such as when a person has an increase in body temperature or has increased perspiration, additional water may be necessary. With an increase in body temperature, there is also an increase in insensible fluid loss. The increased loss of fluid causes an increased need for fluid replacement. If the loss is significant and/or goes untreated, an individual's intake will not be balanced with output. Managing the incision, changing the bed linens, or keeping the client's skin cool are not outcomes indicative of resolution of a fluid volume deficit

A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which goal for this client should take priority?. 1. Conserve energy. 2. Adapt self-care skills. 3. Develop coping skills. 4. Adapt body image

1. Based on the information from the client, the nurse should develop a plan with the client that will conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may have difficulty coping or experience changes in body image as the disorder becomes chronic with increasing pain and fatigue, but the current priority is to conserve energy.

The client diagnosed with osteoarthritis states, "My friend takes steroid pills for her rheumatoid arthritis. Why don't I take steroids for my osteoarthritis?" Which of the following is the best explanation?. 1. Intra-articular corticosteroid injections are used to treat osteoarthritis. 2. Oral corticosteroids can be used in osteoarthritis. 3. A systemic effect is needed in osteoarthritis. 4. Rheumatoid arthritis and osteoarthritis are two similar diseases

1. Corticosteroids are used for clients with osteoarthritis to obtain a local effect. Therefore, they are given only via intra-articular injection. Oral corticosteroids are avoided because they can cause an acceleration of osteoarthritis. Rheumatoid arthritis and osteoarthritis are two different diseases.

A client had a posterolateral total hip replacement 2 days ago. What should the nurse include in the client's plan of care? Select all that apply. 1. When using a walker, encourage the client to keep the toes pointing inward. 2. Position a pillow between the legs to maintain abduction. 3. Allow the client to be in the supine position or in the lateral position on the unoperated side. 4. Do not allow the client to bend down to tie or slip on shoes. 5. Place ice on the incision after physical therapy

2, 3, 4, 5. A client who has had a posterolateral total hip replacement should not adduct the hip joint, which would lead to dislocation of the ball out of the socket; therefore, the client should be encouraged to keep the toes pointed slightly outward when using a walker. An abduction pillow should be kept between the legs to keep the hip joint in an abducted position. The client should rotate between lying supine and lateral on the unoperated side, but not on the operated side. Ice is used to reduce swelling on the operative side. The client should not flex the operated hip beyond a 90-degree angle, such as when bending down to tie or slip on shoes. Doing so could lead to joint dislocation

The client with an open femoral fracture was discharged to the home and developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following reflects the best interpretation of these findings?. 1. Pulmonary emboli. 2. Osteomyelitis. 3. Fat emboli. 4. Urinary tract infection

2. Fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are clinical manifestations of osteomyelitis, which is a pyogenic bone infection caused by bacteria (usually staphylococci), a virus, or a fungus. The bone is inaccessible to macrophages and antibodies for protection against infections, so an infection in this site can become serious quickly. The client with a pulmonary or fat embolus would develop symptoms of pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion. Signs and symptoms of urinary tract infection would include pain over the suprapubic, groin, or back region with fever and chills, with no restrictive movement of the leg.

The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to do which of the following?. 1. Use herbal supplements. 2. Eat a diet high in protein and vitamins C and D. 3. Ask the health care provider for a change of antibiotics. 4. Encourage frequent passive range of motion to the affected extremity.

2. The goal of care for this client is healing and tissue growth while the client continues on long-term antibiotic therapy to clear the infection. A diet high in protein and vitamins C and D promotes healing. Herbal supplements may potentiate bleeding (e.g., ginkgo, ginger, tumeric, chamomile, kelp, horse chestnut, garlic, and dong quai) and have not been proven through research to promote healing. Frequent passive motion will increase circulation but may also aggravate localized bone pain. It is not appropriate to advise the client to change antibiotics as treatment may take time.

The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit?. 1. "I can use heat and cold as often as I want." 2. "With heat, I should apply it for no longer than 20 minutes at a time." 3. "Heat-producing liniments can be used with other heat devices." 4. "Ten to fifteen minutes per application is the maximum time for cold applications."

3. Heat-producing liniment can produce a burn if used with other heat devices that could intensify the heat reaction. Heat and cold can be used as often as the client desires. However, each application of heat should not exceed 20 minutes, and each application of cold should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat, and vasodilation instead of vasoconstriction with cold.

A client has an intracapsular hip fracture. The nurse should conduct a focused assessment to detect:. 1. Internal rotation. 2. Muscle flaccidity. 3. Shortening of the affected leg. 4. Absence of pain in the fracture area.

3. With an intracapsular hip fracture, the affected leg is shorter than the unaffected leg because of the muscle spasms and external rotation. The client also experiences severe pain in the region of the fracture

On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for: 1. Limited motion of joints. 2. Deformed joints of the hands. 3. Early morning stiffness. 4. Rheumatoid nodules.

3. Initially, most clients with early symptoms of rheumatoid arthritis report early morning stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules.

In preparation for total knee surgery, a 200-lb (90.7-kg) client with osteoarthritis must lose weight. Which of the following exercises should the nurse recommend as best if the client has no contraindications?. 1. Weight lifting. 2. Walking. 3. Aquatic exercise. 4. Tai chi exercise

3. When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client's osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss

After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following?. 1. Elevate the SCD on two pillows. 2. Change the settings on the SCD to make the client more comfortable. 3. Stop the SCD to remove dressings and bathe the leg. 4. Discontinue the SCD when the client is ambulatory.

4. After knee arthroplasty, the knee will be extended and immobilized with a firm compression dressing and an adjustable soft extension splint in place. An SCD will be applied. The SCD can be discontinued when the client is ambulatory, but while the client is in bed the SCD needs to be maintained to prevent thromboembolism. The SCD should be positioned on the bed, but not on two pillows. Settings for the SCD are prescribed by the orthopedic surgeon. Initial dressing changes are completed by the orthopedic surgeon and changed as needed per physician prescription.

A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure?. 1. Crackles. 2. Jaundice. 3. Generalized edema. 4. Dark, scanty urine.

4. The client with compartment syndrome may release myoglobin from damaged muscle cells into the circulation. This becomes trapped in the renal tubules, resulting in dark, scanty urine, possibly leading to acute renal failure. Crackles may suggest respiratory complications; jaundice suggests liver failure; and generalized edema may suggest heart failure. However, these are not associated with compartment syndrome.

When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply. 1. The drug can be used if the person is allergic to aspirin. 2. Acetaminophen does not affect platelet aggregation. 3. This drug causes little or no gastric distress. 4. Acetaminophen exerts a strong anti-inflammatory effect. 5. The client should have the international normalized ratio (INR) checked regularly.

1, 2, 3. Acetaminophen is an alternative for a client who is allergic to aspirin. It does not affect platelet aggregation and the client does not need to have coagulation studies (such as INR). Acetaminophen causes little or no gastric distress. Acetaminophen exerts no anti-inflammatory effects.

A client with osteoarthritis will undergo an arthrocentesis on a painful, edematous knee. What should be included in the nursing plan of care? Select all that apply. 1. Explain the procedure. 2. Administer preoperative medication 1 hour before surgery. 3. Instruct the client to immobilize the knee for 2 days after the surgery. 4. Assess the site for bleeding. 5. Offer pain medication

1, 4, 5. To prepare a client for an arthrocentesis, the nurse should tell the client that a local anesthetic administered by the physician will decrease discomfort. There may be bleeding after the procedure, so the nurse should check the dressing. The client may experience pain. The nurse should offer pain medication and evaluate outcomes for pain relief. Because a local anesthetic is used, the client will not require preoperative medication. The client will rest the knee for 24 hours and then should begin range-of-motion and muscle-strengthening exercises.

Of the clients listed below, who is at risk for developing rheumatoid arthritis (RA)? Select all that apply. 1. Adults between the ages of 20 and 50 years. 2. Adults who have had an infectious disease with the Epstein-Barr virus. 3. Adults who are of the male gender. 4. Adults who possess the genetic link, specifically HLA-DR4. 5. Adults who also have osteoarthritis

1,2,4 RA affects women three times more often than men between the ages of 20 and 55 years. Research has determined that RA occurs in client who have had infectious disease, such as the Epstein- Barr virus . The genetic link, specifically HLA-DR4, has been found in 65% of clients with rheumatoid arthritis. People with osteoarthritis are not necessarily at-risk for developing RA

After teaching the client with severe rheumatoid arthritis about prescribed methotrexate, which of the following statements indicates the need for further teaching?. 1. "I will take my vitamins while I'm on this drug." 2. "I must not drink any alcohol while I'm taking this drug." 3. "I should brush my teeth after every meal." 4. "I will continue taking my birth control pills."

1. Because some over-the-counter vitamin supplements contain folic acid, the client should avoid self-medication with vitamins while taking methotrexate, a folic acid antagonist. Because methotrexate is hepatotoxic, the client should avoid the intake of alcohol, which could increase the risk for hepatotoxicity. Methotrexate can cause bone marrow depression, placing the client at risk for infection. Therefore, meticulous mouth care is essential to minimize the risk of infection. Contraception should be used during methotrexate therapy and for 8 weeks after the therapy has been discontinued because of its effect on mitosis. Methotrexate is considered teratogenic

The laboratory notifies the nurse that a client who had a total knee replacement 3 days ago and is receiving heparin has an activated partial thromboplastin time (aPTT) of 75 seconds. After verifying the values, the nurse calls the physician. The nurse should anticipate receiving a prescription for:. 1. Protamine sulfate. 2. Vitamin K. 3. Warfarin (Coumadin). 4. Packed red blood cells

1. The aPTT is at a critical value, and the client should receive protamine sulfate as the antidote for heparin. Vitamin K is the antidote for warfarin. Packed red blood cells are administered to increase the hematocrit

The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which of the following activities is contraindicated?. 1. Assisting with daily hygiene activities. 2. Lying flat in bed. 3. Walking in the hall. 4. Sitting all afternoon in her room

4. After a lumbar laminectomy, a client should not sit for prolonged periods in a chair because of the increased pressure against the nerve root and incision site. Assisting with daily hygiene is an appropriate activity during the initial postoperative period because, as with any surgical procedure, the client needs to return to an optimal level of functioning as soon as possible. There is no limitation on the client's participation in daily hygiene activities except for individual responses of pain, nausea, vomiting, or weakness. Lying flat in bed is appropriate because it does not cause stress on the spinal column where the laminectomy was performed and the disc tissue was removed. Positions that should be avoided are those that would cause twisting and flexion of the spine. Walking in the hall is an acceptable activity. It promotes good postoperative ventilation, circulation, and return of peristalsis, which are needed for all surgical clients. In addition, walking provides the postoperative lumbar laminectomy client an opportunity to build up endurance and muscle strength and to promote circulation to the operative and incision sites for healing without twisting or stressing them.

Following a total hip replacement, the nurse should do which of the following? Select all that apply. 1. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours. 2. Encourage the client to use the overhead trapeze to assist with position changes. 3. For meals, elevate the head of the bed to 90 degrees. 4. Use a fracture bedpan when needed by the client. 5. When the client is in bed, prevent thromboembolism by encouraging the client to do toepointing exercises

1, 3, 4. Administration of antibiotics as prescribed will aid in the acquisition of therapeutic blood levels during and immediately after surgery to prevent osteomyelitis. The nurse can request that a trapeze be added to the bed so the client can assist with lifting and turning. The nurse should also demonstrate and have the client practice isometric exercises (muscle setting) of quadriceps and gluteal muscles. The client will not use crutches after surgery; a physical therapy assistant will initially assist the client with walking by using a walker. The client will not use Buck's traction. The client will require antiembolism stockings and use of a leg compression device to minimize the risk of thrombus formation and potential emboli; the leg compression device is applied during surgery and maintained per physician prescription.