Musculoskeletal

Gout pathology is caused by hyperuricemia, which is defined as a serum urate level greater than either

6.8 or 7

During acute lumbosacral strain, which of the following is the best advice to give about exercising

Back strengthening exercises can cause mild muscle soreness

Jim, age 64, has rheumatoid arthritis (RA). Which of the following drugs would be of the least benefit? A. Disease-modifying antirheumatic drugs (DMARDs) B. Acetaminophen (Tylenol) C. NSAIDs D. Glucocorticoids

Answer B The client with rheumatoid arthritis (RA) benefits from DMARDs, NSAIDs, and steroids because they all treat the disease of RA as well as the pain. Acetaminophen (Tylenol) is a pain reliever but does not have anti-inflammatory effects. Acetaminophen is not considered a treatment option for the disease of RA and is likely even ineffective as a pain reliever for the pain associated with RA.

Jennifer says that she has heard that caffeine can cause osteoporosis and asks you why. How do you respond? A. "Caffeine has no effect on osteoporosis." B. "A high caffeine intake has a diuretic effect that may cause calcium to be excreted more rapidly." C. "Caffeine affects bone metabolism by altering intestinal absorption of calcium and assimilation of calcium into the bone matrix." D. "Caffeine increases bone resorption."

Answer B The effect of caffeine in causing osteoporosis is controversial, but it is postulated to result from caffeine's diuretic effect that causes calcium to be excreted more rapidly.

A nurse practitioner correctly performs the obturator test when the client's leg is raised with knee flexed and the leg is internally rotated. A positive obturator test is indicative of A. avascular necrosis (AVN) of the femoral head. B. cholecystitis. C. hip bursitis. D. appendicitis.

Answer D A positive obturator test, especially with a positive McBurney's point and a positive psoas sign, is indicative of appendicitis. Although internal rotation of the hip may cause hip discomfort in a client with hip bursitis and AVN of the femoral head, the obturator test elicits right lower quadrant (RLQ) abdominal pain, which is indicative of appendicitis.

The nurse practitioner is considering a diagnosis of calcium pyrophosphate dihydrate (CPPD) crystal deposition disease or pseudogout in a 72-year-old man who presents with complaints of pain and stiffness in his wrists and knees. The most useful diagnostic test to assist in confirming this diagnosis would be A. synovial-fluid analysis and x-ray. B. bacterial culture. C. bone scan and MRI. D. anticitrullinated protein antibody (ACPA) test and RA factor.

Answer A CPPD disease (pseudo gout) may appear clinically similar to gouty arthritis; however, in CPPD crystals form in the cartilage and lead to inflammation. The typical age of onset is later in life than for gout and initially presents in the sixth decade of life or later. Diagnosis is made through synovial-fluid analysis and will reveal positive calcium pyrophosphate dihydrate crystals. An x-ray will show radiographic evidence of chondrocalcinosis or calcification in hyaline and/or fibrocartilage in the affected joint. Bacterial cultures would be warranted to aid in diagnosis of cellulitis. Bone scan and MRI are used to differentiate gouty arthritis from Charcot neuroosteoarthropathy. ACPA and an RA factor assist in the diagnosis of rheumatoid arthritis.

First-line drug therapy for acute low back pain includes the use of A. NSAIDs. B. muscle relaxants. C. opioids. D. antidepressants.

Answer A First-line drug therapy for acute low back pain includes the use of NSAIDs. NSAIDs, as well as acetaminophen (Tylenol), have been shown to be as effective as muscle relaxants and opioids for the control of acute low back pain but without the potential for dependence and abuse. Evidence has shown that muscle relaxants are no more effective than NSAIDs in the relief of acute low back pain. Antidepressant drug therapy, particularly tricyclic antidepressants, have been trialed in patients with chronic low back pain even without clinical depression.

The four cardinal signs of inflammation related to musculoskeletal disorders include which of the following? A. Erythema, warmth, fever, or morning stiffness B. Fatigue, morning stiffness, fever, or effusion C. Erythema, warmth, pain or swelling D. Effusion, pain, fever, or swelling

Answer A Inflammatory disorders may be infectious or idiopathic and are identified by all or some of the four cardinal signs of inflammation: erythema, warmth, pain, and swelling. Fatigue, morning stiffness, and fever, along with weight loss, are considered systemic symptoms related to inflammation.

Management of fibromyalgia would include A. giving psychotropic drugs, such as amitriptyline (Elavil), in a low dose at bedtime. B. instructing clients to keep as busy as possible to keep their minds off the symptoms. C. using high doses of NSAIDs. D. avoiding exercise.

Answer A Management of fibromyalgia includes giving tricyclic antidepressants such as amitriptyline (Elavil) in a low dose at bedtime. Although clients with fibromyalgia are fatigued and have stiff joints and muscle pain, physical therapy, including exercise, is an important aspect of care. Injecting trigger points with local anesthetics and steroids can also be helpful. NSAIDs have not proven beneficial in the treatment of fibromyalgia, and NSAIDs are always associated with the risk of gastrointestinal bleeding, especially in high doses.

Marsha, age 34, presents with symptoms resembling both fibromyalgia and chronic fatigue syndrome, which have many similarities. Which of the following is more characteristic of fibromyalgia than of chronic fatigue syndrome? A. Musculoskeletal pain B. Difficulty sleeping C. Depression D. Fatigue

Answer A Musculoskeletal pain is not characteristic of chronic fatigue syndrome; rather, it is characteristic of fibromyalgia. The musculoskeletal pain, usually an achy muscle pain that may be localized or involve the entire body, is usually gradual in onset, although the onset may be sudden, occasionally after a viral illness. Fatigue is a more significant feature of chronic fatigue syndrome. With both disorders, difficulty sleeping and depression occur.

Which diagnostic tests are nonspecific indicators of inflammation and may be elevated in rheumatic disease and polymyalgia rheumatic? A. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) B. Rheumatoid factor (RF) and uric acid C. C-reactive protein (CRP) and fluorescent ANA test D. Fluorescent ANA test and uric acid

Answer A Nonspecific indicators for inflammation are the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). A highly elevated value in either can indicate inflammatory rheumatic disease, infection, or malignancy. Rheumatoid factor (RA) is elevated in only about 75% of patients with rheumatoid arthritis and can also be found in inflammatory conditions such as subacute bacterial endocarditis and vasculitis. A fluorescent ANA test is most often positive in systemic lupus erythematosus (SLE), while an elevated uric acid level is seen in more than 90% of individuals with gout.

Lillian, age 70, was told that she has osteoporosis. When she asks you what this is, you respond that osteoporosis A. develops when loss of bone occurs more rapidly than new bone growth. B. is a degenerative joint disease characterized by loss of cartilage in certain joints. C. is a chronic inflammatory disorder that affects multiple joints. D. is a bone disorder that has to do with inadequate mineralization of the bones.

Answer A Osteoporosis develops when bone resorption occurs more rapidly than bone deposition. Osteoarthritis is a degenerative joint disease characterized by degeneration and loss of articular cartilage in synovial joints. Rheumatoid arthritis is a chronic, systemic inflammatory disorder characterized by persistent synovitis of multiple joints. Osteomalacia is a metabolic bone disorder characterized by inadequate mineralization of bone matrix, often caused by vitamin D deficiency.

Which of the following can assist in the diagnosis of myasthenia gravis? A. Repetitive nerve stimulation B. The presence of cogwheel rigidity C. Chvostek's sign D. Trousseau's sign

Answer A Repetitive nerve stimulation (RNS) is the most frequently used electrodiagnostic test for myasthenia gravis. The nerve to be studied is electrically stimulated, and the compound muscle action potential (CMAP) is recorded with surface electrodes over the muscle. Serological tests such as serum anti-AChR antibodies are also usually included along with electrodiagnostic testing. Cogwheel rigidity is present in Parkinson's disease. Chvostek's and Trousseau's signs are indications of tetany.

Dan, age 49, developed osteomyelitis of the femur after a motorcycle accident. Which of the following statements about the clinical manifestations of osteomyelitis is correct? A. Integumentary effects include swelling, erythema, and warmth at the involved site. B. There is a low-grade fever with intermittent chills. C. Musculoskeletal effects include tenderness of the entire leg. D. Cardiovascular effects include bradycardia.

Answer A The clinical manifestations of osteomyelitis include the integumentary effects of swelling, erythema, and warmth at the involved site, as well as drainage and ulceration through the skin and lymph node involvement, especially in the involved extremity. The client with osteomyelitis may also have tachycardia, localized tenderness, and a high fever with chills.

Colchicine may be used to terminate an acute attack of gouty arthritis as well as to prevent recurrent episodes. The mechanism of action is to A. interrupt the cycle of urate crystal deposition and inflammatory response. B. increase serum uric acid levels. C. potentiate the excretion of uric acid. D. inhibit the tubular reabsorption of urate, promoting the excretion of uric acid.

Answer A The mechanism of action of colchicine is to interrupt the cycle of urate crystal deposition and inflammatory response. Used to treat an acute attack of gout, colchicine does not alter serum uric acid levels. Colchicine is generally used as a second-line therapy in gout when NSAIDs or corticosteroids are contraindicated or ineffective. Allopurinol (Zyloprim) acts on purine metabolism to reduce the production of uric acid and decrease serum and urinary concentrations of uric acid. It is useful for prevention of gout but not in the treatment of acute gout.

The straight leg-raising maneuver can be used to diagnose A. nerve root compression. B. a fractured hip. C. an anterior cruciate ligament tear. D. tendinitis.

Answer A The straight leg-raising maneuver can be used to diagnose nerve root compression by eliciting radiating pain down the leg in the affected dermatomal distribution. The leg is straight and lifted by the heel. The leg may also be brought across the body to increase the sensitivity of this maneuver. Leg shortening and external rotation may be present with a fractured hip. Extending the knee will elicit pain if an anterior cruciate ligament tear is present. Pressure over an affected tendon will elicit pain if tendinitis is present.

Which of the following is a modifiable risk factor for osteoporosis? A. Low alcohol intake B. Low caffeine intake C. Smoking D. Excessive exercise

Answer C Modifiable risk factors for osteoporosis include smoking, high caffeine intake, high alcohol intake, sedentary lifestyle, calcium deficiency, and estrogen deficiency. Over the course of their lives, women tend to lose up to one-third of their original bone mass, ultimately affecting 80% of their skeletal system. It is essential that modifiable risk factors be modified because there are many that cannot, including increasing age, race (incidence is greater in white women), gender, pale complexion, and long-term glucocorticoid therapy.

To diagnose fibromyalgia, there must be tenderness on digital palpation in at least 11 of 18 (nine pairs) tender point sites, which would include the A. occiput, low cervical, trapezius, and supraspinatus. B. proximal interphalangeal (PIP), meta-carpophalangeal (MCP) joints of the hands, and the metatarsophalangeal (MTP) and PIP joints of the foot. C. facet joints of the cervical, thoracic, and lumbar spine. D. radial and ulnar styloids and the medial and lateral malleoli.

Answer A To diagnose fibromyalgia, there must be tenderness on digital palpation in at least 11 of 18 (nine pairs) tender point sites, including the occiput, low cervical, trapezius, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter, and knee. PIP, MCP, and MTP joint tenderness occurs primarily in rheumatoid arthritis. Facet joints of the spine are often tender in facet arthritis. Tenderness over the bony prominences of the wrist and ankle would be specific to injury at those areas.

Ankylosis is defined as A. muscle shortening. B. joint stiffness. C. malposition of a joint. D. dislocation of a joint.

Answer B Ankylosis is defined as stiffness or immobility in a joint caused by bones fusing as a result of disease or injury or intentionally through surgery. It is not a result of muscles shortening or of joint malposition or dislocation.

Black men have a relatively low incidence of osteoporosis because they have A. increased bone resorption. B. a higher bone mass. C. wide and thick long bones. D. decreased bone deposition.

Answer B Black men have a relatively low incidence of osteoporosis because they have higher levels of bone mass and are protected by the bone-resorptive effects of parathyroid hormone. Osteoporosis has the highest incidence in white women.

A 55-year-old patient presents with complaints of paresthesias into the lower lateral arm, thumb, and middle finger. The most commonly involved nerve roots that cause the related symptoms are C6 and C7. The most likely differential diagnosis would be A. brachial plexis neuritis. B. cervical radiculopathy. C. peripherial polyneuropathy. D. thoracic outlet syndrome.

Answer B Cervical nerve root compression of C6 and C7 is termed cervical radiculopathy. Brachial plexus neuritis presents with dysfunction ranging from momentary paresthesias to completely flail extremities and is usually caused by injuries to the C5 and C6 nerve roots. Peripheral polyneuropathy is associated with distal sensorimotor paresthesia with diminished deep tendon reflexes. Thoracic outlet syndrome is compression of the brachial plexus and/or subclavian vessels as they exit the space between the superior shoulder girdle and the first rib. Symptoms are color changes in the hand with sensory changes and weakness in the fourth and fifth fingers.

Mrs. Kelly, age 80, has a curvature of the spine. This is likely to indicate which age-related change? A. Lordosis B. Dorsal kyphosis C. Scoliosis D. Kyphoscoliosis

Answer B Dorsal kyphosis, an exaggerated convexity of the thoracic curvature, typically accompanies the aging process. Lordosis occurs when the normal lumbar concavity is further accentuated, such as with pregnancy or obesity. Scoliosis, which is more prevalent in adolescent girls, is a lateral S-shaped or C-shaped curvature of the thoracic and/or lumbar spine and can also involve vertebral rotation.

Cass, age 67, tells the nurse practitioner (NP) that she has been diagnosed with a condition that causes sudden flares of pain, swelling, and redness of the joints in her toes. She cannot remember the name of the diagnosis, but she knows that it is caused by urate crystals that "get stuck in the joint and cause pain." Joan is on hydrochlorothiazide (HCTZ) for management of her hypertension. The NP should suspect a diagnosis of A. septic arthritis. B. gout. C. rheumatoid arthritis. D. Charcot neuro-osteoarthropathy.

Answer B Gout is a disorder that involves abnormal metabolism of uric acid and results in hyperuricemia. High concentrations of urate precipitate into crystals that collect in tissue and joint spaces and can cause pain and inflammation. It is likely that the patient's symptoms may be aggravated by the use of HTCZ. Like gout, septic arthritis presents with an acute onset of swelling, pain, and heat in a joint. However, unlike gout, it occurs most frequently in the knee followed by the hip, shoulder, wrist, and ankle. Rheumatoid arthritis typically affects multiple joints simultaneously and is a slow and progressive disease. Charcot neuro-osteoarthropathy occurs in diabetic patients presenting as hot, swollen, and red joints. These patients usually report a history of trauma, surgery, or prior infection.

When grading muscle strength on a scale of 1 to 5, a grade of 4 indicates A. full range of motion (ROM) against gravity with full resistance. B. full ROM against gravity with some resistance. C. full ROM with gravity. D. full ROM with gravity eliminated (passive motion).

Answer B In grading muscle strength on a scale of 1 to 5, a grade of 4 indicates full range of motion (ROM) against gravity with some resistance. A grade of 5 is full ROM against gravity with full resistance. A grade of 3 is full ROM with gravity. A grade of 2 is full ROM with gravity eliminated (passive motion). A grade of 1 indicates slight muscle contraction. A grade of 0 indicates no muscle contraction.

Jessie, age 49, states that she thinks she has rheumatoid arthritis. Before any diagnostic tests are ordered, the nurse practitioner completes a physical examination and makes a differential diagnosis of osteoarthritis rather than rheumatoid arthritis. Which clinical manifestation ruled out rheumatoid arthritis? A. Fatigue B. Affected joints are swollen, cool, and bony hard on palpation C. Decreased range of motion D. Stiffness

Answer B In osteoarthritis, the affected joints are swollen, cool, and bony hard on palpation. With rheumatoid arthritis, the affected joints appear red, hot, and swollen and are boggy and tender on palpation. Fatigue, decreased range of motion, and joint stiffness are common to both diseases.

Mike, age 42, a golf pro, has had chronic back pain for many years. His work-up reveals that it is not the result of a degenerative disk problem. His back "goes out" about twice per year, and he is out of work for about a week each time. Which of the following should the nurse practitioner advise him to do? A. Consider changing careers to a less physical job B. Begin a planned exercise program to strengthen back muscles C. Make an appointment with a neurosurgeon for a surgical consultation D. Start on a daily low-dose narcotic to take away the pain

Answer B In this case, Mike may benefit from a regular planned exercise program to strengthen back muscles and attempt to reduce the probability of future episodes of back pain. Surgery is recommended only for clients with low back pain caused by degenerative disk disorders, and then only when severe neurological involvement has occurred. Surgery benefits only approximately 1% of persons with low back problems. Suggesting a career change should be considered only in cases of disability or inability to safely continue one's current employment. Narcotic pain medications are not considered first-line treatment for mechanical back pain.

Upon assessment, the nurse practitioner notes unilateral back pain that had an acute onset and increases when standing and bending. A straight-leg test is negative. The most likely differential diagnosis is A. herniated nucleus pulposus. B. muscle strain. C. osteoarthritis. D. spondylolisthesis.

Answer B Muscle strain is usually located in the low back and is unilateral in location. The onset is acute, and pain increases with standing and bending and decreases when sitting. The straight leg-raising test and plain film x-ray are both negative. Herniated nucleus pulposus causes unilateral back pain that is acute and increases when sitting or bending but decreases when standing. The straight leg-raising test is positive, and the plain film x-ray is negative. Back pain related to osteoarthritis is usually bilateral in nature and has an insidious onset. Pain increases when standing and decreases when sitting. A straight leg-raising test is negative, with a plain film x-ray that is positive. Spondylolisthesis has an insidious onset, and low back pain increases when standing or bending and decreases when sitting. A straight leg-raising test is negative, while a plain film x-ray is positive.

You are caring for a patient who has a history of psoriasis and now is showing signs of joint involvement. Seropositivity provides a definitive diagnosis of psoriatic arthritis (PsA). The initial treatment choice for management of the patient is A. disease-modifying antirheumatic drugs (DMARDs). B. NSAIDs. C. tumor necrosis factor-alpha inhibitors (TNF-α inhibitors). D. uricosuric.

Answer B NSAIDs are the first-line treatment for musculoskeletal signs and symptoms with joint involvement. DMARDs, such as methotrexate, are used for early-stage treatment of active disease with structural damage and inflammation. Biological agents, or TNF-α inhibitors, are considered for patients with active disease and inadequate response to one or more systemic DMARDs or very active psoriatic arthritis (PsA). A uricosuric such as Probenecid, with the addition of the anti-inflammatory colchicine, is indicated for chronic gouty arthritis.

June, age 67, presents with back pain with no precipitating event. The pain is located over her lower back and muscles without sciatica, and it is aggravated by sitting, standing, and certain movements. It is alleviated with rest. Palpation localizes the pain, and muscle spasms are felt. There was an insidious onset with progressive improvement. What is the most likely differential diagnosis? A. Ankylosing spondylitis B. Musculoskeletal strain C. Spondylolisthesis D. Herniated disk

Answer B Pain over the lower back and spine as well as the muscles without sciatica is musculoskeletal strain. Often there is no precipitating event, and there is an insidious onset. It is aggravated by sitting, standing, and certain movements. Palpation localizes the pain, and muscle spasms may be felt. It is alleviated by rest, and there is progressive improvement. Ankylosing spondylitis is back pain and stiffness over several months, where there is a systemic inflammatory condition of the vertebral column and sacroiliac joints. Painful ankylosed sacroiliac joints, reduced chest wall expansion, and excessive thoracic kyphosis are also present. It most frequently affects males between the ages of 20 and 30, causing chronic low back pain that is worse in the morning. There is relief with exercise and reduced mobility of the spine. A herniated disk is often preceded by years of recurrent episodes of localized back pain, and there is usually leg pain that overshadows the back pain. With spondylolisthesis, there is a defect or fracture of the pars interarticularis with forward shifting of one vertebra on top of another. This can cause nerve irritation and damage if the vertebrae are pressing on a spinal nerve root.

Greg, age 26, runs marathons and frequently complains of painful contractions of his calf muscles after running. You attribute this to A. hypercalcemia. B. hyponatremia. C. heat exhaustion. D. dehydration.

Answer B Painful contractions of muscles after exertion, such as heat cramps, may be related to hyponatremia or other electrolyte imbalances. Usually the gastrocnemius and hamstring muscles are involved. Treatment of heat cramps includes passive muscle stretching, cessation of activities, transfer to a cooler environment, and drinking cool liquids. Sports drinks such as Gatorade that contain electrolytes may be beneficial. Heat exhaustion is a more serious condition, with symptoms ranging from nausea, vomiting, headache, loss of appetite, and dizziness to irritability, tachycardia, and hyperventilation. Hyperkalemia may cause muscular weakness, fatigue, and muscle cramps. Greg's dehydration is attributed to his hyponatremia and would be a good second-choice answer. Hypercalcemia may affect gastrointestinal, renal, and neurological function. Symptoms may include constipation and polyuria, as well as nausea, vomiting, and anorexia at times.

Anna, age 42, is pregnant and was just given a diagnosis of carpal tunnel syndrome. She is worried that this will affect her in caring for the baby. What do you tell her? A. "Don't worry; we'll find a brace that is very malleable." B. "After childbirth, your carpal tunnel syndrome may resolve." C. "If we do surgery now, you'll be recovered by the time the baby arrives." D. "You should prepare yourself for the probability of being unable to care for your baby."

Answer B Pregnant women have an increased incidence of carpal tunnel syndrome (CTS) but often have their carpal tunnel syndrome resolve after delivery. Although repetitive use of the hand can lead to carpal tunnel syndrome, certain medical conditions such as diabetes, obesity, and thyroid disease also increase the likelihood of CTS. Often, the cause of CTS is unknown. Most likely, Anna will be able to care for her baby and will not need surgery and/or a brace.

Carol, age 62, has swollen, bony proximal interphalangeal joints. The nurse practitioner describes these as A. Heberden's nodes. B. Bouchard's nodes. C. Osler's nodes. D. Murphy's nodes.

Answer B Swollen, bony proximal interphalangeal joints are Bouchard's nodes. Bony enlargements of the distal interphalangeal joints are Heberden's nodes. Both suggest osteoarthritis. Osler's nodes are painful, raised lesions of the fingers, toes, or feet that occur with bacterial endocarditis. There are no Murphy's nodes.

Christian, age 22, is a carpenter who is right-hand dominant. He comes to the clinic for follow-up from the emergency department where he was seen for right forearm pain. He states he was diagnosed with right forearm tendinitis and wants the provider to explain this diagnosis to him. Patient teaching should explain that he has inflammation of one or more tendons, which are A. the ropelike bundles of collagen fibrils that connect bone to bone. B. the collagen fibers that connect muscle to bone. C. the pouches of synovial fluid that cushion bone and other joint structures. D. the fibrocartilaginous disks that separate bony surfaces.

Answer B Tendons are the collagen fibers that connect muscle to bone. Ligaments connect bone to bone in the joints. Bursae are the pouches of synovial fluid that reduce friction between bones, muscles, or tendons. Fibrocartilaginous disks separate bony surfaces such as those between the vertebrae in the spine.

Jeffrey, age 16, was involved in a motor vehicle accident. He walks into the office with an obvious facial fracture and then collapses. What should the first action of the nurse practitioner be? A. Call his parents for permission to treat B. Assess for an adequate airway C. Obtain head and maxillofacial CT D. Assess for a septal hematoma

Answer B The primary concern in the management of facial fractures is to ensure an adequate and stable airway. Displaced soft tissues, blood, secretions, or other foreign material may obstruct the airway and cause asphyxia. Septal hematomas are more commonly seen in children than in adults, but the first priority is to maintain an adequate airway. Once his airway is established and he is stabilized, permission to treat Jeffrey can be obtained from his parents. Head and maxillofacial CT would then be obtained.

Margaret, age 55, presents to you for evaluation of left hand and wrist pain and swelling after a slip and fall on the ice yesterday. On examination, you note tenderness at her "anatomical snuffbox." You knows this probably indicates a(n) A. ulnar styloid fracture. B. scaphoid fracture. C. hamate fracture. D. radial head fracture.

Answer B There is tenderness over the "anatomical snuffbox" in a scaphoid (aka navicular) fracture, the most common injury of the carpal bones. Poor blood supply puts the scaphoid bone at risk for avascular necrosis; therefore, wrist pain and tenderness in the anatomical snuffbox, even without history of antecedent trauma, warrants a wrist x-ray. A fracture of the hook of the hamate is an uncommon fracture seen in golfers and in players of other racket sports and involves pain and tenderness on the ulnar side of the palm. An ulnar styloid fracture would produce tenderness at the distal ulna. A radial head fracture would result in pain at the elbow joint where the radial head lies proximal to the distal humerus. Be sure not to confuse the radial head (proximal end of the radius) with the radial styloid (distal end of the radius at the wrist).

Sean, a factory line worker, has osteoarthritis of the right hand. According to the American College of Rheumatology (ACR), the guidelines for pharmacological treatment include A. acetaminophen, tramadol, and intra-articular corticosteroid injections. B. oral NSAIDs, Tramadol, and articular corticosteroid injections. C. acetaminophen, topical capsaicin, and topical NSAIDs. D. topical capsaicin, topical NSAIDs, and oral NSAIDs.

Answer B Topical capsaicin, topical NSAIDs, oral NSAIDs and tramadol are recommended by the American College of Rheumatology (ACR) for the treatment of osteoarthritis (OA) of the hand. They also conditionally recommend against using intraarticular therapies or opioid analgesics. For patients older than age 75, topical versus oral NSAIDs are recommended. The ARC conditionally recommends acetaminophen, oral NSAIDs, topical NSAIDs, tramadol, and intra-articular corticosteroid injections for OA of the knee. Acetaminophen, oral NSAIDs, tramadol, and intra-articular corticosteroid injections are recommended for initial management of hip OA.

Treatment of choice for polymyalgia rheumatica (PMR) is A. acetaminophen or NSAIDs. B. low-dose steroids. C. tricyclic antidepressants. D. antibiotics.

Answer B Treatment for PMR consists of low-dose steroids, starting with 10 to 15 mg and tapering to 5 to 7.5 mg daily for several weeks or months. PMR is not an infectious process; thus, there is no need for antibiotics. Tricyclic antidepressants do not address the underlying etiology of this condition and thus should not be ordered. Tylenol and/or NSAIDs do not provide sufficient anti-inflammatory action.

When teaching Alice, age 77, to use a cane because of osteoarthritis of her left knee, an important point to stress is to tell her to A. carry the cane in the ipsilateral hand. B. advance the cane with the ipsilateral leg. C. make sure that the cane length equals the height of the iliac crest. D. use the cane to aid in joint protection and safety.

Answer B When teaching clients about using a cane, tell them to advance the cane with the ipsilateral (affected) leg. The cane should be carried in the contralateral hand, and the cane length should equal the height of the greater trochanter. The use of assistive devices is an important strategy to protect the joints, as well as provide safety, but clients must be taught the proper use of all devices.

The most common cause of cauda equina syndrome is A. fracture. B. hematoma. C. lumbar intervertebral disk herniation. D. space-occupying lesion.

Answer C A herniated lumbar intervertebral disc is the most common cause of cauda equina syndrome (CES). Other causes of CES include trauma, fracture, hematoma, abscess, lymphoma, tumor, and other space-occupying lesions that compress the spinal nerve roots.

Heidi, age 29, is a nurse who has an acute episode of back pain. You have determined that it is a simple "mechanical" backache and order A. bedrest for 2 days. B. muscle relaxants. C. her to continue activities as the pain permits. D. back-strengthening exercises.

Answer C Faster symptomatic recovery has been seen in clients with a simple "mechanical" backache who continue normal activities as much as they can with "pain being their guide" than in clients who use traditional medical treatments, such as bedrest and use of NSAIDs. Muscle relaxants should be ordered only if muscle spasms are actually present, although acetaminophen (Tylenol) and NSAIDs have also been shown to help the muscle spasms adequately. Back-strengthening exercises should be started within 6 weeks of the onset of pain.

Which of the following is NOT a management principal for an acute musculoskeletal injury that does not require emergent treatment? A. RICE B. NSAIDs or acetaminophen C. Imaging studies D. Skeletal muscle relaxants

Answer C Imaging studies such as radiograph, CT scan, and MRI are usually not indicated for acute musculoskeletal injuries. Rest, ice for 48 hours, compression with an ace wrap, and elevation (which make up the acronym RICE) are commonly employed. NSAIDs and acetaminophen are the first-line choices for medication management in acute injury or pain. Skeletal muscle relaxants prescribed for a 1-to 2-week course may be valuable if the injury is accompanied by spasm or tightness.

The knee is an example of a A. spheroidal joint. B. hinge joint. C. condylar joint. D. fibrous joint.

Answer C In a condylar joint, such as the knee and temporomandibular joint, the articulating surfaces are convex or concave and are termed condyles. Spheroidal joints have a ball-and-socket configuration—a rounded convex surface articulating with a cuplike cavity, allowing a wide range of rotary movement, as in the shoulder and hip. Often the knee is mistakenly referred to as a hinge joint, but hinge joints are flat and uniplanar, allowing only a gliding motion in a single plane, as in flexion and extension of the interphalangeal joints. In fibrous joints, such as the sutures of the skull, intervening layers of fibrous tissue or cartilage hold the bones together. The bones are almost in direct contact, which allows no appreciable movement.

When a provider elicits a painful Finkelstein's sign, he or she is testing for A. carpal tunnel syndrome. B. bursitis of the shoulder. C. de Quervain's tenosynovitis. D. tennis elbow.

Answer C Pain elicited when the Finkelstein's test is performed indicates de Quervain's tenosynovitis at the base of the thumb. The test is performed by flexion of the thumb across the palm, with ulnar deviation of the wrist. Gliding the inflamed tendons will produce pain, which is considered a positive Finkelstein's test. Tinel's sign and Phalen's test are used to diagnose carpal tunnel syndrome. The tennis elbow test evaluates for lateral epicondylitis. The client's elbow is stabilized in the examiner's hand and the thumb of that hand positioned on the client's lateral epicondyle. The client makes a fist, pronates the forearm, and radially deviates and extends the wrist while the examiner applies a resisting force at the wrist. This test is positive if pain is elicited in the area of the lateral epicondyle. There is no specific test for shoulder bursitis.

Anne Marie states that she has a maternal history of rheumatoid disease but that she has never been affected. Today she presents with complaints of dryness of the eyes and mouth. What is the most likely differential diagnosis? A. Rheumatoid arthritis B. Systemic lupus erythematosus C. Sögren's syndrome D. Rosacea

Answer C Sögren's syndrome, which affects the salivary and lacrimal glands, causes clients to have dry eyes and mouths. It is an inflammatory disease of the exocrine glands and may be an isolated entity or may be associated with other rheumatic disease, such as rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE). Because Anne Marie has no other symptoms of RA or SLE, Sögren's syndrome should be considered first. Rosacea is a chronic facial skin disorder with a vascular component.

The Valgus stress test, Varus stress test, Lachman test, and Thumb test are all considered standard tests to check the integrity of the ligaments of the knee. Which test would the nurse practitioner choose to assess the anterior cruciate ligament, which is the most commonly involved structure in severe knee injury? A. Valgus stress test B. Varus stress test C. Lachman test D. Thumb sign

Answer C The Lachman test assesses the anterior cruciate ligament (ACL) while the Thumb test assesses the posterior cruciate ligament (PCL). The Valgus stress test assesses stability of the medial collateral ligament (MCL), and the Varus stress test determines stability of the lateral collateral ligament (LCL).

Mr. McKinsey, age 69, was recently given a diagnosis of degenerative joint disease. Which assessment test should the nurse practitioner use to check for effusion of the patient's knee? A. The Thomas test B. Tinel's sign C. The bulge test D. Phalen's test

Answer C The bulge test assesses for an effusion of the knee. If effusion is present, a bulge will appear to the sides of or below the patella when the practitioner compresses the area above the patella. The Thomas test is used to assess for hip problems. Both the Tinel's sign and Phalen's test assess for carpal tunnel syndrome.

Bursitis is an inflammatory process that may be caused by infection, trauma, repetitive movement disorders, gout, or neoplastic disease. The most common cause of septic bursitis due to infection is from which of the following? A. Mycobacterium tuberculosis B. Candida C. Staphylococcus aureus D. Streptococcus

Answer C The most common causative organism of septic bursitis is Staphylococcus aureus (80% of cases), followed by streptococci. However, many other organisms have been implicated in septic bursitis, including mycobacteria (both tuberculous and nontuberculous strains), fungi (Candida), and algae (Prototheca wickerhamii). Factors predisposing to infection include diabetes mellitus, steroid therapy, uremia, alcoholism, skin disease, and trauma. A history of noninfectious inflammation of the bursa also increases the risk of septic bursitis.

Steve, age 32, fell off a roof while shingling it. He is complaining of pain in his left hip and leg area. Other than an x-ray, what would make you suspect a fractured pelvis? A. A clicking sensation when moving the hips B. A positive pelvic tilt test C. Hematuria D. Absence of distal reflexes

Answer C To determine if a client has a fractured pelvis, a test for hematuria will usually prove positive. A fracture of the pelvis usually results in hypovolemia caused by a generally significant associated blood loss. Surrounding blood vessels rupture, which results in a large retroperitoneal hematoma with shock. Pelvic fractures also commonly injure the urinary bladder or urethra. A client with a fracture in several locations of the pelvis may need a pneumatic anti-shock garment to control the blood loss and stabilize the pelvis. Only x-ray studies will confirm the diagnosis. A clicking sensation when moving the hips is not diagnostic of a fractured pelvis, and a positive pelvic-tilt test is not an evidence-based physical exam technique. Absence of distal reflexes is also not correlated with a fracture of the pelvis.

Jim, age 22, a stock boy, has an acute episode of low back pain. The nurse practitioner orders an NSAID and should educate him in which of the following? A. Maintain moderate bedrest for 3 to 4 days. B. Call the office for narcotic medication if there is no relief with the NSAID after 24 to 48 hours. C. Begin lower back strengthening exercises depending on pain tolerance. D. Wear a Boston brace at night.

Answer C Years ago, muscle relaxants and bedrest were the treatments of choice for low back pain. Studies have now shown that resuming normal activity within the limits imposed by the pain has an effect as good as, if not better than, 2 days of bedrest. The expression is "let pain be your guide." Exercise should begin as soon as possible after the acute injury and is directed at building endurance and stamina with consideration given to one's pain tolerance. NSAIDs, not narcotics, are generally the first-line medication treatment of low back pain without the risk of opioid dependency. A Boston brace may be used in the treatment of scoliosis.

Beth, age 49, comes in with low back pain. An x-ray of the lumbar/sacral spine is within normal limits. Which of the following diagnoses do you explore further? A. Scoliosis B. Osteoarthritis C. Spinal stenosis D. Herniated nucleus pulposus

Answer D A plain x-ray film will not show a herniated nucleus pulposus or a muscle strain. It will show spondylolisthesis, scoliosis, osteoarthritis, and spinal stenosis. Note that x-rays of the spine are not indicated in low back pain unless the cause of the pain is thought to have a bony origin or to be traumatic in nature or to rule out systemic disease.

Sandy, age 49, presents with loss of anal sphincter tone, impaired micturition, incontinence, and progressive loss of strength in the legs. You suspect cauda equina syndrome. What is your next action? A. Order physical therapy B. Order a lumbar/sacral x-ray C. Order extensive lab work D. Refer to a neurosurgeon

Answer D A prompt referral to a neurosurgeon is required when a diagnosis of cauda equina syndrome is suspected. Cauda equina syndrome is a widespread neurological disorder in which there is loss of anal sphincter tone; impaired micturition and incontinence; saddle anesthesia at the anus, perineum, or genitals; and motor weakness or sensory loss in both legs. An x-ray is not helpful in the diagnosis of cauda equina, and precious time should not be wasted in a client with suspected cauda equina. An MRI can be a useful diagnostic tool, but prompt evaluation by a neurosurgeon is an essential first step to prevent permanent neurological damage.

If any limitation or any increase in range of motion occurs when assessing the musculoskeletal system, the angles of the bones should be measured using A. Phalen's test. B. skeletometry. C. the Thomas test. D. a goniometer.

Answer D If any limitation or increase in range of motion (ROM) occurs when assessing the musculoskeletal system, the angles of the bones should be measured with a goniometer, which gives precise measurements of joint ROM. Phalen's test is used to diagnose carpal tunnel syndrome; it is not a tool. Skeletometry does not exist. The Thomas test is for evaluation of hip ROM.

Mrs. Matthews, age 71, has rheumatoid arthritis. On reviewing an x-ray of her hip, you notice that there is a marked absence of articular cartilage. What mechanism is responsible for this? A. Antigen-antibody formation B. Lymphocyte response C. Immune complex formation D. Lysosomal degradation

Answer D Lysosomal degradation results when leukocytes produce lysosomal enzymes that destroy articular cartilage in rheumatoid arthritis. The collagen fibers and the protein polysaccharides of articular cartilage are broken down by the enzymes. Immune complexes initiate the inflammatory process that brings leukocytes to the cartilage. Immune complexes are formed by the combination of immunoglobulin G with rheumatoid factors that are the result of antigen-antibody formation.

Which test is routinely recommended for a preparticipation sport physical? A. A complete blood count B. A chest x-ray C. An electrocardiogram D. A Snellen test

Answer D Other than a gross eye examination (most commonly performed using a Snellen eye chart) and vital signs, no specific tests are routinely recommended for a preparticipation sport physical.

Joan, age 76, has been given a diagnosis of osteoporosis confirmed with a dual-energy x-ray absorptiometry (DEXA) scan. The nurse practitioner has educated her about the importance of increasing calcium and vitamin D in her diet and starting a low-impact, weight-bearing exercise program. The nurse practitioner is also going to start the patient on medial management. Joan asks about a drug called a "SERM" that she has heard has been shown in studies to prevent vertebral fractures. Which of the following pharmacological therapies for osteoporosis is classified as a selective estrogen receptor modulator (SERM)? A. Alendronate (Fosamax) B. Risedronate (Actonel) C. Salmon calcitonin D. Raloxifene (Evista)

Answer D Raloxifene is a selective estrogen receptor modulator. Intranasal salmon calcitonin has been shown effective for pain management of osteoporotic fracture, but data on fracture incidence with this treatment are not available. Alendronate and risedronate are classified as bisphosphonates and can be used for prevention and treatment of osteoporosis.

A clinical manifestation of symmetric neurogenic pain may indicate A. radiculopathy. B. reflex sympathetic dystrophy. C. entrapment neuropathy. D. peripheral neuropathy.

Answer D Symmetric neurogenic pain (burning, numbness, and tingling) will include peripheral neuropathy and myelopathy. Asymmetric neurogenic pain will include radiculopathy, reflex sympathetic dystrophy, and entrapment neuropathy. A claudication pain pattern will be present in peripheral vascular disease, giant-cell arteritis (with jaw pain), and lumbar spinal stenosis. These conditions all include the clinical manifestations of neurogenic pain.

Janine, age 69, has a class III case of rheumatoid arthritis. According to the American Rheumatism Association, her function would be A. adequate for normal activities despite a handicap of discomfort or limited motion of one or more joints. B. largely or wholly incapacitated, bedridden, or confined to a wheelchair, permitting little or no self-care. C. completely able to carry on all usual duties without handicaps. D. adequate to perform only few or none of the duties of usual occupation or self-care.

Answer D The American Rheumatism Association has identified functional classes I to IV depending on the client's ability to accomplish activities of daily living. Because Janine is a class III, her function would be adequate to perform only few or none of the duties of usual occupation or self-care. Class I refers to the client who can carry on all usual duties without handicaps. Class II refers to the client whose function is adequate for normal activities despite a handicap of discomfort or limited motion at one or more joints. Class IV refers to the client who is largely or wholly incapacitated, bedridden, or confined to a wheelchair, permitting little or no self-care.

Hilda, age 73, presents with a complaint of low back pain. Red flags in her history of a minor fall, osteopenia, and prolonged steroid use for systemic lupus erythematosus suggest the possibility of which of the following serious underlying conditions as the cause of her low back pain? A. Cancer B. Cauda equina syndrome C. Neurological compromise D. Spinal fracture

Answer D The red flags for spinal fracture include major trauma or a direct blow the back in adults, a minor fall or heavy lifting in a potentially osteoporotic or elderly person, prolonged steroid use, and age over 70. Low back pain accompanied by acute onset of urinary retention or overflow incontinence, loss of anal sphincter tone or fecal incontinence, loss of sensation in the buttocks and perineum, and motor weakness in the lower extremities are red flags for cauda equina syndrome or severe neurologic compromise. Cancer may be suspected if the low back pain is accompanied by unexplained weight loss and immunosuppression in a person over age 50.

To aid in the diagnosis of meniscus damage, which test should a nurse practitioner perform? A. The bulge test B. The Lachman test C. The drawer test D. Apley's compression test

Answer D To aid in the diagnosis of meniscus damage such as a torn meniscus, you should perform Apley's compression test. With the client in the prone position, the suspected knee is flexed to 90 degrees and then downward pressure is exerted on the foot so that the tibia is firmly opposed to the femur. The leg is then rotated externally and internally. If the knee locks and there is pain or clicking with this maneuver, it is a positive Apley's sign, indicating the presence of a loose body, such as a torn cartilage, trapped in the joint articulation. The bulge test assesses for effusion in the knee joint. The Lachman test is an indicator of injury to the anterior cruciate ligament. The drawer test assesses for stability of the anterior and posterior cruciate ligaments.

For an adult patient with a knee injury, the nurse practitioner orders an NSAID to be taken on a routine basis for the next 2 weeks. Patient teaching should include which of the following? A. "You may take this medication on an empty stomach as long as you eat within 2 to 3 hours of taking it." B. "If one pill does not seem to help, you can double the dose for subsequent doses." C. "If you notice nausea/vomiting or black or bloody stools, take the next dose with a glass of milk or a full meal." D. "If you have additional pain, an occasional acetaminophen (Tylenol) is permitted in between the usual doses of the NSAID."

Answer D When teaching clients about NSAIDs, tell them not to take these drugs on an empty stomach but to take them with food or milk and to stop the medication and call immediately if they notice any nausea/vomiting, coffee-ground emesis, black stools, or blood in the stool. If the client is having additional pain, acetaminophen (Tylenol) may be taken in conjunction with an NSAID because it is not an NSAID and will not potentiate gastric bleeding. Clients should be taught to never take more than the prescribed dose of an NSAID due to the likelihood of increasing the chances of gastrointestinal (GI) damage and kidney damage.

A person with a grade III ankle sprain will present with

Complete ankle instability, significant swelling and moderate to severe eccymosis

According to the 2012 task force panel of the ACR a patient with stable disease and simple, chronic, tophaceous gouty arthropathy (CTGA) affecting two to four joints is classified as

moderate

Which joints are most likely to be affect by osteoarthritis

DIP

Upon physical examination, enlargement of an 83-year-old's distal interphalangeal joints is noted. Enlargement of these joints is known as

Heberden Nodes

A 52-year-old male postal worker drives a truck everyday. He presents with lower back pain and has decreased sensation to a pinprick in the lateral leg and web of the great toe. This indicates discogenic disease in which area L3/L4 (L4 root involvement) L4/L5 (L5 root involvement) L5/S1 (S1 root involvement) none of the above

L4/L5 (L5 root involvement)

A 46-year-old patient presents with a tender, red, swollen knee. A presumptive diagnosis of acute gout may be made by all of the following except: a negative joint culture hyperuricemia a significant response to colchicine or a nonsteroidal anti-inflammatory drug a positive antinuclear antibody test

a positive antinuclear antibody test

A 72-year-old has severe osteoarthritis of her right knee. She obtains much relief from corticosteroid injections. When she asks you how often she can have them, how do you respond? only once a year no more than twice a year no more than 3 times a year no more than 4 times a year

no more than 3 times a year

A 55 year old male has developed a slight limp and pain in his right leg which is worse with weight bearing. These complaints are most associated with

osteoarthritis

Glucosamine sulfate is a natural supplement that is used for which condition

osteoarthritis

First-line pharmacologic intervention for milder osteoarthritis should be a trial of

acetaminophen

A female computer programmer has just been given a diagnosis or carpal tunnel syndrome. Our next step is to: suggest surgery take a more complete history try neutral position wrist splinting and order and oral nonsteroidal anti-inflammatory drug do electrophysiologic testing

try neutral position wrist splinting and order and oral nonsteroidal anti-inflammatory drug

In clients with arthritis, the goals of exercise include all of the following except: reversing muscular atrophy increasing periarticular support decreasing intra-articular nutrient diffusion stimulating cartilage regeneration and repair without promoting further damage

decreasing intra-articular nutrient diffusion

A 48-year-old male has asymptomatic hyperuricemia. What is your initial therapy? nonsteroidal anti-inflammatory drugs dietary counseling colchicine allopurinol (Zyloprim)

dietary counseling

A 38-year-old female has rheumatoid arthritis and gets achy and stiff after sitting through a long movie. This is referred to as: longevity stiffness gelling intermittent arthritis molding

gelling