Care of Patients with Musculoskeletal Problems

The nurse plans to refer a patient diagnosed with osteoporosis to which community resource?

National Osteoporosis Foundation Patients with musculoskeletal problems should be referred to appropriate community resources, like the National Osteoporosis Foundation. The American Bone Society does not actually exist. CanSurmount is a cancer support group geared toward patient and family education. I Can Cope is also a support group for patients with cancer.

The nurse is caring for a patient who is scheduled to undergo a procedure to remove a ganglion cyst in the wrist. What does the nurse tell the patient about the procedure?

A needle will be used to aspirate the fluid. A needle is used to aspirate the fluid under local or regional anesthesia. A patient who has surgery for Dupuytren's contracture undergoes partial or selective fasciectomy. After removal of the surgical dressing, a splint is applied to the wrist for support. The patient undergoing removal of the ganglion is asked to avoid strenuous activity for the next 48 hours to promote healing. An ice pack should not be applied after surgery.

The nurse completes a teaching session on safe drug administration for a patient with Paget's disease taking oral bisphosphonates. Which patient statement indicates a need for further teaching?

"I should go to sleep immediately after taking the drug." Oral bisphosphonates can cause stomach upset, inflammation, and erosions of the esophagus. This can be prevented by remaining upright for 30 to 60 minutes after taking the medication. Oral hygiene should be maintained as long as the drug is taken. Patients taking bisphosphonates are more prone to develop osteonecrosis of the jaw, so invasive surgical procedures are to be avoided. The drug should be stopped 3 months prior to any invasive dental treatment to prevent complications.

A patient with bone cancer is scheduled for a right upper extremity amputation. Which statement by the patient's husband indicates an effective coping strategy?

"I'll have to find ways to help my wife focus on positive aspects of her body." Planning to help the patient focus on positive aspects of her body illustrates that the husband is coping with the change in his wife's body image in a positive way. Planning to have the family avoid direct discussion of the amputation does not allow the patient the opportunity to discuss her feelings about the loss of a limb. Visitors could be a source of comfort and may provide a way for the patient to express her feelings, so visitors should not be limited. Using diversional methods to help the patient not focus on the amputation is not an effective coping strategy; it limits the chance for the patient to discuss feelings about the amputation.

What is the pathophysiology of Paget's disease in its correct sequence of occurrence?

1. Formation of giant, multinucleated osteoclasts 2. Initiation of osteoclastic activity 3. Bone destruction and deformation 4. Initiation of osteoblastic activity 5. Formation of structurally weak bone In the active phase of the Paget's disease, there is a predominant increase in the giant, multinucleated osteoclasts. The osteoclastic activity causes bone destruction that is followed by osteoblastic activity as a response to the bone destruction. The osteoblasts form the bone, but it is weak and deformed with high vascularity.

A patient has a callus of the foot. What treatment does the nurse anticipate for this patient?

Application of padding and lanolin cream Callus is a poorly defined mass on the sole over a bony prominence caused by pressure. It is treated with padding and lanolin cream. The patient should be taught to maintain overall good hygiene; an untreated ingrown nail causes hypertrophic ungual labium and requires surgical removal of the necrotic nail and skin, followed by treatment for secondary infection. An ingrown nail also penetrates the skin and causes inflammation; the sliver is removed by a podiatrist. The patient is then prescribed warm soaks and antibiotic treatment.

Which type of muscular dystrophy seen in adults usually begins between 5-25 years of age?

Becker The onset of Becker (Benign X-Linked) dystrophy is seen between 5-25 years of age. The onset of Myotonic (Steinert) dystrophy is seen between birth to 40 years of age. The onset of Limb-Girdle dystrophy is usually seen between 20-30 years of age. The onset of Facioscapulohumeral (Landouzy-Dejerine) dystrophy is usually seen in the 20s.

After dental work, a female patient taking medications for osteoporosis reports pain, bleeding gums, and halitosis. Upon examination, the bone is found to be exposed. Which medication is the cause for this condition?

Bisphosphosphonates Bisphosphonates are associated with osteonecrosis of the jaw that may cause apoptosis of the osteoclasts in the bone. Estrogen agonist and antagonists act by inhibiting the differentiation of osteoclasts. Calcium supplements do not cause osteonecrosis.

What is the most common assessment finding associated with osteoporosis?

Bone fractures Osteoporosis is a chronic metabolic disorder due to either primary or secondary causes that lead to bone loss, which in turn can cause frequent fractures. Bone pain is often associated with osteomyelitis or bone cancer. Bone abscesses are seen in osteomyelitis. Bone enlargement is seen with bone tumors.

Which is the hormonally active metabolite of vitamin D that directly regulates serum calcium levels?

Calcitriol Calcidiol is converted to the metabolite calcitriol in the kidneys, where the calcitriol directly regulates the calcium levels in circulation. Calcitriol promotes absorption of dietary calcium from the gastrointestinal tract, increasing renal tubular reabsorption. Cholecalciferol is converted to calcidiol in the liver. Vitamin D has two important groups, vitamin D2, called ergocalciferol, and vitamin D3, known as cholecalciferol.

What are the common causes of osteomalacia? Select all that apply.

Crohn's disease Hypophosphatemia Chronic kidney disease Barbiturate therapy Osteomalacia is a bone disorder related to vitamin D deficiency. Crohn's disease causes decreased vitamin and mineral absorption that can lead to osteomalacia. Hypophosphatemia stimulates calcium movement from bone and prevents calcium uptake in the bone which can result in osteomalacia. Chronic kidney disease interferes with the synthesis of calcitriol, the most active metabolite of vitamin D, and can cause osteomalacia. Osteomalacia can be an adverse effect of barbiturate therapy. Estrogen agonist/antagonists increase bone density and are used to treat and prevent osteoporosis. Pseudomonas aeruginosa can cause bone infection leading to osteomyelitis, rather than osteomalacia.

What complication of osteoporosis can cause a patient to lose up to 3 inches of height in 20 years?

Dowager's hump A dowager's hump can happen as a result of osteoporotic changes that collapse the vertebrae. This causes a forward slumping of the shoulders and a loss of 2-3 inches of height over a period of 20 years. Osteopenia is a medical condition in which the protein and the mineral content of bone tissue becomes reduced. Fallophobia is a fear of falling. Osteomalacia is a softening of the bones due to calcium loss.

Which is a deformity of the hand?

Dupuytren's contracture Dupuytren's contracture is a thickening of the fibrous tissue layer underneath the skin of the palm and fingers. A bunion is a painful swelling on the first joint of the big toe. A sarcoma is a type of cancer that develops from certain tissues, like bone or muscle. Plantar fasciitis is one of the most common causes of heel pain. It involves pain and inflammation of a thick band of tissue, called the plantar fascia, which runs along the bottom of the foot and connects the heel bone to the toes. Morton's neuroma is an injury to the nerve between the toes, which causes thickening and pain. The injury is caused due to the growth of a small tumor in a digital nerve of the foot.

Which term describes a benign tumor arising from cartilage?

Endochondroma Endochondroma, or chondroma, is a benign tumor arising from cartilage. This type of tumor primarily affects the hands and the feet. Osteochondroma is a benign tumor but arises from both bone and cartilage. Osteosarcoma is a malignant bone tumor. Giant cell tumor is a benign tumor of the bone.

The nurse admits a patient diagnosed with Paget's disease. The nurse anticipates that the patient will have which condition?

Enlarged, thick skull An enlarged thick skull is a feature of Paget's disease. Progressive muscle weakness is a feature of muscular dystrophy. Low body weight with a thin build is a feature of osteoporosis. Bone infection is a feature of osteomyelitis.

The nurse is caring for a patient with an open wound from chronic osteomyelitis. How does the nurse ensure that this patient receives increased tissue perfusion?

Exposing the affected area to a high concentration of oxygen. The nurse would apply a portable device to administer a high concentration of oxygen by hyperbaric therapy. This treatment increases tissue perfusion for patients with chronic unremitting osteomyelitis. The nurse should apply clean technique when changing dressings and caring for contaminated wounds. Wound irrigation is done to clean wounds by debridement; this is managed through the window of a cast. Standard Precautions for wound care are used to care for wounds that are not draining; in this case, the wound is not draining, only covered.

Which statement is true regarding a ganglion cyst? Select all that apply

Ganglion cysts can rapidly disappear and recur. Treatment includes the aspiration of cystic fluid with a fine needle. Ganglion cysts form due to the degeneration of synovium surrounding the tendon A ganglion is a round, benign cyst usually found on a wrist, foot joint, or tendon. These cysts may rapidly disappear and then recur. The fluid within the cyst can be aspirated through a small needle, and the ganglion can be relieved. The cyst is formed due to the degeneration of synovium surrounding the tendon. These cysts are benign and painless on palpation.

What type of foot disorder appears as a bump on the side of the big toe?

Hallux valgus A bunion (also referred to as hallux valgus or hallux abducto valgus) is often described as a bump on the side of the big toe. A hammertoe occurs due to the pressure of poorly fitting shoes; the metatarsophalangeal (MTP) joint becomes disfigured and permanently bends to the side. Plantar fasciitis is one of the most common causes of heel pain; it involves pain and inflammation of a thick band of tissue, called the plantar fascia, which runs along the bottom of the foot and connects the heel bone to the toes. Morton's neuroma is an injury to the nerve between the toes, which causes pain. The injury happens due to the growth of a small tumor in the digital nerve of the foot.

Which risk factor is shared by patients who have osteoporosis or osteomalacia?

High alcohol intake High alcohol intake is a risk factor for both osteoporosis and osteomalacia. A history of smoking is a risk factor for osteoporosis only. Inadequate exposure to sunlight and homelessness are risk factors for osteomalacia only.

What is the pathophysiology of osteoporosis?

Increased osteoclastic activity over osteoblastic activity Bone is a dynamic tissue that is constantly undergoing changes in a process referred to as bone remodeling. Osteoclasts resorb the bone, while osteoblasts build the bone. Osteoporosis occurs when osteoclastic activity is greater than osteoblastic activity, resulting in decreased bone density. Osteocytes are inert cells that do not participate in bone formation. Increased osteocytic activity will not cause bone resorption, while increased osteoblastic activity will enhance bone formation, thereby increasing bone density.

The nurse is teaching a patient ways to increase vitamin D in the diet using natural foods (unfortified). Which food choices indicate the patient understands the teaching? Select all that apply.

Milk Eggs Tofu Liver Milk, eggs, tofu, and liver are unfortified foods that are rich in vitamin D. Cheese derived from milk rarely contains vitamin D although it is rich in calcium. Cereals do not naturally contain high amounts of vitamin D. Commercially available cereals may be enriched (fortified) with vitamin D.

Which foot disorder causes small tumor growth in a digital nerve of the foot?

Morton's neuroma Morton neuroma is an injury to the nerve between the toes, which causes pain. The injury is caused by the growth of a small tumor in a digital nerve of the foot. A callus is a thickened and hardened part of the skin or soft tissue that usually appears in an area that has been subjected to friction. Plantar fasciitis is one of the most common causes of heel pain. It involves pain and inflammation of the thick band of tissue, called the plantar fascia, which runs from the bottom of the foot and connects the heel bone to the toes. Hypertrophic ungual labium is chronic hypertrophy of the nail lip caused by improper nail trimming.

A patient is diagnosed with Morton's neuroma. How might a patient describe the pain associated with a Morton's neuroma? Select all that apply.

Pain is acute. Pain is in the web space Pain is burning in nature Morton's neuroma is a small tumor that grows in a digital nerve of the foot. The pain is usually described as an acute and burning sensation in the web space. The pain involves the entire surface of the third and fourth toes.

What are the risk factors for primary osteoporosis? Select all that apply.

Parental history of osteoporosis Thin build with low body weight Chronic low calcium and vitamin D intake Evidence demonstrates that genetics is a very important contributing factor for primary osteoporosis; 50% to 90% of cases are hereditary. People with a thin build and low body weight have relatively low bone density, which leads to osteoporosis. A diet with decreased calcium and vitamin D intake stimulates the parathyroid gland to produce parathyroid hormone (PTH). PTH triggers the release of calcium from the bony matrix. Vitamin D is required for calcium absorption by the body. Estrogen helps prevent bone loss and postmenopausal patients have estrogen deficiency; long-term corticosteroid drug therapy results in secondary osteoporosis. Immobilization of a limb following a fracture leads to regional osteoporosis.

A patient has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon?

Paresis of right lower extremity Paresis indicates a neurovascular compromise that must be reported immediately to the surgeon. The patient undergoing a sequestrectomy experiences increased swelling after the procedure; the affected extremity should be elevated to increase venous return and thus control swelling. Palpable pulses of 1+ to 2+ bilaterally are a sign of adequate blood flow. Pain on movement of the right lower extremity is an expected finding.

What is the generic name for the bisphosphonate drug zoledronic acid?

Reclast Bisphosphonates are a category of drugs that prevent the loss of bone mass and are used to treat osteoporosis and similar diseases. The other names for zoledronic acid are Reclast and Zometa. Ibandronate is generic for Boniva. Risedronate is the generic name for actonel and atelvia. Alendronate is the generic name for fosamax or fosamax plus D.

Which term is used to describe the condition in which the spinal column begins to move into a lateral curve, most commonly in the right lateral thoracic area?

Scoliosis Scoliosis is a musculoskeletal disorder in which there is a sideways curvature of the spine, or backbone. It happens when the vertebrae rotate and compress. Due to scoliosis, the spinal column begins to move into a lateral curve, most commonly in the right lateral thoracic area. Lordosis is a musculoskeletal disorder in which the spine in the lower back has an excessive curvature. A chondroma is a lesion of mature hyaline cartilage. Osteosarcomas are cancers of the bone.

After removing the cast from a nondisplaced ulnar bone fracture in the 8th week after being injured, the patient reports pain and swelling at the site. Further investigations revealed a fracture of the right radial bone. What might be the reason behind the fracture?

Secondary osteoporosis Secondary osteoporosis may result from certain medical conditions, medications, or lifestyle behavior like prolonged immobilization. The patient's arm being immobilized for 8 weeks resulted in secondary osteoporosis, leading to a fracture of the radial bone. Primary osteoporosis occurs due to age-related or idiopathic factors. Primary and secondary osteomyelitis is infection of the bone characterized by infective manifestations such as fever, pus discharge, and sinus tract formation.

A patient diagnosed with a benign bone tumor is being discharged. What does the nurse teach the patient about self-management?

Take prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) after meals or with food The patient should be taught to take prescribed NSAIDs after meals or with food to reduce gastrointestinal effects. This patient would not be provided with IV patient-controlled analgesia, as this is mainly used for postoperative pain management and end-stage cancer. The patient is permitted to use hot or cold compresses for pain relief as per preference. There is nothing to indicate that the patient needs assistance to ambulate; a benign bone tumor does not necessarily affect gait or balance.

What should the nurse infer if the T-score of a patient is -2 in a bone mineral density (BMD) test?

The patient has osteopenia The BMD test helps to compare the patient's bone density to a healthy 30-year-old adult's bone density. If the patient's BMD is equal to the control, then the T-score will be 0. A T score from -1 to -2.5 indicates osteopenia. A T-score lower than -2.5 indicates osteoporosis. The greater the negative number, the more severe osteoporosis would be.

The nurse is assessing a patient with scoliosis. What does the degree of curvature of the spine in scoliosis signify? Select all that apply.

The spine is unstable if the curvature is over 50 degrees Cardiopulmonary function is compromised if curvature is more than 60 degrees. Patients are prescribed exercises if curvature is less than 50 degrees. Scoliosis presents as a lateral curvature of the vertebral spine. If the lateral curvature is greater than 50 degrees, it may result in an unstable spine and cardiopulmonary function is compromised. If the curvature is less than 50 degrees, the condition can be managed conservatively by encouraging exercises and the application of moist heat. In adults, this disorder is progressive and may result in deviation of the spine by one degree each year. Surgical intervention is preferred if the curvature is greater than 50 degrees to prevent osteoarthritis, shortness of breath, and fatigue.

A patient has recently undergone surgery to treat osteomyelitis. What are the signs of neurovascular compromise after the surgery? Select all that apply.

Pulselessness Paresis or paralysis Paresthesia Uncontrollable pain The signs of neurovascular compromise are pulselessness, paresis or paralysis presented as weakness or inability to move, and paresthesia presented as an abnormal tingling sensation. In addition, the patient may also experience uncontrollable pain. Purulent discharge indicates infection rather than neurovascular compromise. Pallor, rather than erythema, is a sign of neurovascular compromise.

The nurse provides a patient with information about how to prevent osteomalacia. Which statement made by the patient indicates the need for further teaching?

"I should exclude chicken and swordfish from my diet." Patients with osteomalacia have a vitamin D deficiency. Foods such as chicken and swordfish are rich in vitamin D; therefore, the nurse recommends that the patient eat more chicken and swordfish. Patients diagnosed with osteomalacia should take vitamin D daily. Dairy products are rich sources of vitamin D; therefore, the nurse instructs the patient to include dairy products in the diet. Sunlight is a natural source of vitamin D; therefore, the nurse instructs the patient to expose him or herself to the sun for at least 5 minutes a day.

Which statements by a lactose intolerant osteoporotic patient who sustained a hip fracture indicate the need for further teaching about proper dietary measures? Select all that apply.

"I will eat a high-fat diet to enhance bone healing." "I will try to eat dairy products to enhance calcium levels." A high-fat diet is found to interfere with calcium absorption. Lactose intolerant patients will experience digestive discomfort after consuming lactose-containing foods; instead, calcium- and vitamin D-fortified foods, soy milk, and soy products should be included in the diet. A protein-rich and iron-rich diet enhances bone healing.

A nurse counsels a patient about a minimally invasive surgical procedure to treat idiopathic adult scoliosis. Which statement made by the patient indicates the need for further instruction?

"I will have a long hospital stay after the surgery." Minimally invasive surgical procedures are performed using endoscopic instrumentation. As a result, there is a small incision site and reduced post-operative complications such as pain and infection. Due to fewer complications, the duration of the hospital stay is also minimized.

An older adult patient is discharged from the hospital for treatment of osteoporosis. What does the nurse include in patient teaching related to the patient's home safety?

"Keep walkways free of clutter." Walkways in the home must be clear of clutter and obstacles to help prevent falls. Patients with metabolic bone problems should not use area rugs at home because they may cause tripping or falling. Patients with metabolic bone problems must not walk on wet floors because the potential for falling is too great. Keeping the lights low would not allow the patient to see adequately to walk safely or avoid an object on the floor.

The nurse is caring for a patient with bone cancer of the right hip who has undergone radical resection of the tumor and has received a prosthetic implant. Which patient statement indicates effective coping after the procedure?

"Physical therapy and counseling will help me adjust to my prosthesis." The patient stating that physical therapy and counseling will help him or her to adjust to the prosthesis illustrates effective coping and acceptance. The patient expecting to be just as strong as before the surgery or expecting to return to work and drive without assistance reveal that the patient is in denial of how surgery will affect his or her prognosis and activity. Avoiding going out in public suggests that the patient is having difficulty coping and adjusting to his or her changed body image.

The nurse is instructing a patient who has been prescribed calcium citrate. Which instruction does the nurse include?

"Take calcium citrate with food." Calcium supplements can cause gastric upset; taking calcium citrate with food can minimize gastric upset. Calcium citrate should be taken with 6-8 ounces of water, not carbonated beverages. One-third of the daily dose is best taken at bedtime. MOM is not indicated and actually may lead to decreased absorption of calcium citrate.

What is the pathophysiology of sequestrum formation in osteomyelitis? Arrange the process in the correct order.

1. Invasion of pathogenic microorganisms 2. Stimulation of inflammatory response 3. Vascular thrombosis 4. Release of exudate into the bone tissue 5. Ischemia of bone tissue 6. Sequestrum Invasion of pathogenic microorganisms stimulates the inflammatory response in bone tissue. Once inflammation is established, the vessels in the area become thrombosed and release exudate (pus) into bony tissue. Ischemia of bone tissue follows and results in necrotic bone. This area of necrotic bone separates from surrounding bone tissue, and sequestrum is formed.

What is the usual dosage of the drug alendronate, when given to a patient for the prevention of osteoporosis?

5 mg orally daily or 35 mg orally weekly The usual dosage of alendronate that is given to a patient for the prevention of osteoporosis is 5 mg orally daily, or 35 mg orally weekly (available as tablet or liquid). For treatment, the usual dosage of alendronate is 10 mg orally daily, or 70 mg orally weekly. The usual dosage of 5 mg IV once a year is appropriate for zoledronic acid, which is used to prevent osteoporosis. For treatment, it is 5 mg IV once in every 2 years.

A 67-year-old patient is diagnosed with plantar fasciitis. What conservative management does the nurse suggest? Select all that apply.

Apply an ice pack to the site. Strap the affected foot. Wear shoes with good support. Plantar fasciitis is an inflammation of the plantar fascia presenting as severe pain in the arch of the foot. The patient should be instructed to apply an ice pack to the site to reduce inflammation. The patient should also strap the affected foot to maintain the arch and wear shoes that provide good support and comfort. The patient should provide rest to the area and perform stretching exercises to relax the muscles of the feet. Cortisone and nonsteroidal anti-inflammatory drugs (NSAIDs) are used to control pain and inflammation.

A patient with an osteoporotic vertebral fracture is prescribed raloxifene. What does the nurse include in the assessment of this patient?

Assess for a history of venous thromboembolism. Raloxifene is an estrogen agonist and is often used in the treatment of osteoporotic vertebral fracture. This drug is not given to patients with a history of venous thromboembolism (VTE) because it increases the risk of VTE in the first 4 months of therapy. Patients taking bisphosphonates are at risk for jaw necrosis. Liver functions tests are monitored for raloxifene (Evista), not the CBC. Drowsiness, agitation, and anxiety are some of the central nervous system side effects of risedronate, a biphosphonate.

A patient has undergone surgery on a lower extremity for a primary bone tumor. What intervention does the nurse perform for this patient?

Assess neurovascular status of the extremity every 1 to 2 hours after the surgery. The nurse must assess the neurovascular status of the extremity every 1 to 2 hours after surgery. A major complication of this surgery is rapid deterioration in circulation, which must be reported immediately. A continuous passive motion (CPM) machine is used from the first postoperative day for patients who had an upper extremity surgery. The patient is assisted to reach full weight-bearing by 3 months postoperatively. Ambulation does not start until partial weight bearing is applicable.

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)?

Check the vital signs for a patient who was admitted after a total knee replacement 3 hours ago. Vital sign assessment is a skill that is within the role of the UAP. Removing a wound drain, assessment, and patient teaching are nursing actions that require broader education and are within the scope of practice of licensed nursing staff.

In what type of sarcoma does the patient experience dull pain and swelling for a long period?

Chondrosarcoma A chondrosarcoma is one of the most common bone sarcomas seen in adulthood. It is usually associated with dull pain and swelling for a long period. A fibrosarcoma is a malignant (cancerous) tumor that originates in the connective fibrous tissue found at the ends of the bones of the arm or legs before spreading to other surrounding soft tissues. Pain or soreness is caused by suppressed nerves and muscles. Osteosarcomas are the most common type of primary malignant bone tumors. The tumor is relatively large, causing acute pain and swelling. Ewing's sarcoma is not as common as other tumors; it is the most malignant. Like other primary tumors, it causes pain and swelling but also leucocytosis and a low-grade fever.

Which category of osteomyelitis is related to a bone infection that is caused by a skin infection of the adjacent tissues?

Contiguous In contiguous osteomyelitis, any deep infection in the soft tissue wound adjacent to the bone can be a source of osteomyelitis. Exogenous osteomyelitis can occur when the bone protrudes through the skin during an open fracture. It allows a potentially infectious organism to enter from an abscess or burn, a puncture wound, or other trauma. Endogenous (also called hematogenous) osteomyelitis occurs when organisms are carried by the bloodstream to the bone from other areas of infection in the body.

What is Dupuytren's contracture?

Contracture of the hand due to palmar fibromatosis Dupuytren's contracture, or deformity, is a slowly progressive thickening of the palmar fascia (known as palmar fibromatosis) that results in flexion contracture of the fourth (ring) and fifth (little) fingers of the hand. Contracture occurring due to fibrosis within the muscle is an organic contracture, whereas contracture due to acute ischemia or necrosis of the muscle fibers of the flexor group of muscles is Volkmann's contracture. Ischemic contracture is due to interference with the circulation due to pressure, injury, or cold.

An 80-year-old patient with uncontrolled hypertension reports pain in the right foot and is diagnosed with a hallux valgus deformity. What is the most appropriate treatment?

Custom-made shoes Patients with advanced age, uncontrolled hypertension, uncontrolled diabetes mellitus, and other medical conditions are not good candidates for surgery. Thus, custom-made shoes that fit the deformed feet are suggested to provide comfort and support. For patients who are medically fit for surgery, a bunionectomy (removal of bony overgrowth and bursa), osteotomy (excision of bony overgrowth), and stabilization of the bone with screws can be performed.

Which is one of the causes of secondary osteoporosis?

Diabetes mellitus Secondary osteoporosis may result from medical conditions such as diabetes mellitus, hyperthyroidism, and hyperparathyroidism; long-term drug therapy, such as with corticosteroids; or prolonged immobility. Primary osteoporosis is more common and occurs in postmenopausal women and in men in their 70-80s. The risk factors or causes of primary osteoporosis include older age, smoking, and high alcohol intake.

What is a hammertoe?

Dorsiflexion of the metatarsophalangeal joint with plantar flexion of the proximal interphalangeal joint next to it Having the toes bent for long periods of time can cause the toe muscles to shorten, resulting in a hammertoe deformity. Hammertoe is the dorsiflexion of the metatarsophalangeal joint with plantar flexion of the proximal interphalangeal joint next to it. Deformity of the great toe joint where the hallux is deviated medially (towards the midline of the body) away from the first metatarsal bone is called hallux varus. Stiffness due to bone spurs that affect the metatarsophalangeal joint at the base of the hallux (big toe) is called hallux rigidus. Deformity characterized by medial deviation of the first metatarsal and lateral deviation of the hallux (big toe) is called hallus valgus.

A patient is suspected of having Paget's disease. What x-ray finding is suggestive of the disorder?

Enlargement of bones with a radiolucent, punched-out appearance When seen on an x-ray, Paget's disease presents with an enlarged bone that has a radiolucent, punched-out appearance. Smooth, uniform periosteal bone appearance on x-ray is seen in benign bone tumors. Poor demonstration of bone margins on x-ray is usually observed in cancerous bone tumors. The classic diagnostic finding on an x-ray specific for osteomalacia is the presence of Looser's zones. These appear as radiolucent bands which represent stress fractures that have not mineralized.

The nurse is caring for an older adult patient diagnosed with osteomalacia. The nurse anticipates that the health care provider will request which medication?

Ergocalciferol Osteomalacia is loss of bone related to vitamin D deficiency. The major treatment for osteomalacia is vitamin D in an active form such as ergocalciferol. Ascorbic acid (vitamin C) is not indicated for treatment of osteomalacia, which is related to vitamin D deficiency. Phenytoin interferes with the metabolism of vitamin D. Prednisone is a glucocorticoid for treatment of inflammatory disorders and is not indicated in the treatment of osteomalacia.

Which is a key feature of acute osteomyelitis?

Fever Fever or temperature above 101° F (38.3° C), swelling around the affected area, and erythema of the affected area are some of the key features of acute osteomyelitis. Foot ulcers, localized pain, sinus tract formation, and drainage from the affected area are the key features of chronic osteomyelitis.

What complication of osteomyelitis is the most likely to occur?

Formation of bone abscesses The most common complication of osteomyelitis is the formation of bone abscesses. Infection stimulates the inflammatory response in the bone and the surrounding tissue which leads to necrosis. The necrotic bone forms a sequestrum when it gets separated from the surrounding bone tissue; this sequestrum acts as a focus for ongoing infection and forms a bone abscess. Pathologic fractures, malignant transformation, and secondary arthritic changes are usually seen in osteitis deformans and also with osteomalacia and bone tumors.

A nurse notices the lateral drift of the greater toe at the first metatarsophalangeal joint. What would be the expected diagnosis by the primary health care provider?

Hallux valgus Hallus valgus is a deformity characterized by medial deviation of the first metatarsal and lateral deviation of the hallux. Hammertoe is the dorsiflexion of the metatarsophalangeal joint with plantar flexion of the proximal interphalangeal joint next to it. Deformity of the great toe joint where the hallux is deviated medially away from the first metatarsal bone is called hallux varus. An inflammation of plantar fascia on the arch of the foot is called plantar fasciitis.

Which long-term drug therapies may cause secondary osteoporosis? Select all that apply.

Heparin Furosemide Cyclosporine Aluminum/magnesium antacid Long-term drug therapy with heparin, loop diuretics such as furosemide, immunosuppressants such as cyclosporine, and aluminum-based antacids like Mylanta may cause secondary osteoporosis. Ergocalciferol is an active form of vitamin D that is administered along with calcium for the treatment of osteoporosis. Bisphosphonates such as alendronate are also commonly used in the treatment of osteoporosis as they slow down bone resorption by binding with crystal elements in spongy, trabecular bone tissue.

The nurse is assessing a patient with osteomalacia. Which findings does the nurse expect to observe? Select all that apply.

Hypophosphatemia Looser's lines or zones Unsteady gait Osteomalacia is loss of bone related to vitamin D deficiency, which can lead to bone softening and inadequate deposits of calcium and phosphorus in the bone matrix; this may cause hypophosphatemia. Looser's lines or zones (radiolucent bands) represent stress fractures and are a classic diagnostic finding of osteomalacia. Muscle weakness in the lower extremities may cause waddling and an unsteady gait. Hyperparathyroidism and hyperuricemia may be observed in Paget's disease.

The nurse is developing a plan of care for a patient with metastatic bone cancer. What is an appropriate goal of treatment to include in the plan of care for this patient?

Improve the quality of life and promote pain relief The management of metastatic bone cancer is palliative and not curative; therefore, interventions are aimed at improving the quality of life and promoting pain relief. Determining the stage of cancer and extent of bone damage helps in planning the treatment of bone cancer and its metastatic lesions. Curing cancerous bone, cartilage, and metastatic lesions is of secondary importance in management of metastatic bone cancer; palliation is more important. Reconstruction of bone and bone grafting are surgical interventions of less importance in the palliative management of metastatic bone cancer.

The x-ray of a patient shows a radiolucent appearance of bones in the pelvic region. Which other findings would confirm the diagnosis of Paget's disease? Select all that apply.

Increased uric acid levels Increased alkaline phosphatase levels Increased urinary hydroxyproline levels Increases in serum alkaline phosphatase (ALP) and urinary hydroxyproline levels are the primary laboratory findings in Paget's disease and often cause an elevated uric acid because overactive bone metabolism increases nucleic acid. Decreased alkaline phosphatase levels and decreased urinary hydroxyproline would not indicate the presence of Paget's disease.

The nurse is teaching a group of nursing students about osteitis deformans. What statement made by a student nurse indicates the need for further instruction?

It affects women twice as often as it affects men Osteitis deformans, or Paget's disease, is a chronic metabolic disorder of the bone. Men are affected twice as often as women. It may present as low back pain and sciatic nerve pain due to nerve impingement in the lumbosacral area of the vertebral column. Paget's disease may cause secondary hyperparathyroidism that leads to increased levels of serum and urinary calcium. This in turn results in calcium deposits as renal or urinary calculi. Bones affected by Paget's disease may rarely develop malignant changes such as osteogenic sarcoma. Paget's disease is characterized by rapid bone destruction (osteoclastic activity) followed by bone regeneration (osteoblastic activity).

What risk factor is associated with primary osteoporosis?

Lack of physical exercise Lack of physical exercise and sedentary lifestyle are some of the risk factors associated with primary osteoporosis in postmenopausal women. Weight-bearing exercises reduce bone resorption or loss, and in turn, stimulate bone formation, thus preventing osteoporosis. Diabetes mellitus, increased levels of thyroid hormone, and long-term treatment with corticosteroids are risk factors for secondary osteoporosis.

The nurse is teaching the importance of nutrition to a 74-year-old patient who is lactose-intolerant and at risk for osteoporosis. What nutritional considerations does the nurse teach? Select all that apply.

Limit consumption of carbonated beverages. Avoid excessive intake of alcohol and caffeine. Drink fruit juices fortified with calcium. Ensure adequate intake of vitamins C and K, magnesium, and iron. The nurse should teach the patient to limit consumption of carbonated beverages, since drinking over 40 ounces per day of carbonated drinks causes calcium loss. Excessive intake of alcohol and caffeine promotes acidosis and causes bone loss. Alcohol also has a direct toxic effect resulting in decreased bone formation and increased bone resorption. Since lactose-intolerant patients cannot take milk and milk products, the nurse should advise fruit juices fortified with calcium and vitamin D. Adequate intake of vitamins C and K, magnesium, and iron promote bone formation and bone healing. Excessive protein intake increases calcium loss in urine and should be avoided. It is recommended that patients over the age of 71 take 800 to 1000 international units of activated vitamin D per day.

The nurse is teaching a young patient about ways to prevent osteoporosis in later adulthood. Which information does the nurse provide?

Limit the consumption of carbonated beverages. The consumption of 40 ounces of carbonated beverages causes calcium loss; patients should limit their intake of carbonated beverages to prevent osteoporosis later in life. People on a high-protein, low-carbohydrate diet like the Atkins diet tend to replace other foods with protein; excessive protein intake increases calcium loss in the urine. Weight-bearing exercise reduces bone resorption and stimulates bone formation; people with low body weight and thin build are predisposed to osteoporosis. Exposure to the sun between 10:00 AM and 3:00 PM is not recommended; however, exposure to sunlight before 10:00AM is recommended as a good source of vitamin D.

The medical history of a patient reporting severe intermittent pain from the flank to the groin on the right side shows that the patient is osteoporotic and is on calcium supplements. Which condition should the nurse anticipate?

Nephrolithiasis The formation of nephroliths (stones) in the kidney is called nephrolithiasis. It is characterized by severe, intermittent pain from the flank to the groin in the right side and is caused by calcium supplementation. Diverticulitis is the inflammation of diverticulum, especially in the colon, and is manifested as a similar pain, but on the left side. Appendicitis and pyelonephritis are associated with inflammation and are not a cause for pain in the flank to the groin.

Which drug regimen should be prescribed to regulate the serum alkaline phosphatase levels in a patient suffering from Paget's disease who has a serum alkaline phosphatase level of 210 IU/L?

Oral bisphosphonates Oral bisphosphonates should be prescribed to the patients whose serum alkaline phosphotase levels are more than twice the normal range. Calcitonin is useful in the treatment of postmenopausal osteoporosis. Calcium supplements do not regulate the alkaline phosphotase levels in serum. NSAIDS such as ibuprofen should be prescribed only in conditions of mild to moderate pain.

Which bone disorder is characterized by localized rapid bone destruction and bone formation that commonly affects the vertebrae, femur, skull, clavicle, humerus, and pelvis?

Osteitis deforman Osteitis deformans (Paget's disease) is a chronic metabolic disorder of the bone characterized by rapid bone destruction followed by unorganized bone regeneration. The new bone formed is vascular, structurally weak, and deformed, resulting in pathological fractures and bowing of long bones. Osteomalacia is a metabolic bone disorder caused by the deficiency of vitamin D and characterized by inadequate bone mineralization. Osteoporosis is a chronic metabolic disorder characterized by a decrease in total bone mass and an increased susceptibility to fractures. Osteomyelitis is an infection of the bone that spreads from adjacent soft-tissue infection, direct bone contamination, or hematogenous spread.

What interventions may be utilized to manage a patient with chronic osteomyelitis? Select all that apply.

Packing the wound with bone cement bead impregnated with antibiotic Irrigating wounds through the window of a cast Exposing the affected area to hyperbaric oxygen therapy Osteomyelitis wounds should be packed with beads made of bone cement impregnated with an antibiotic. This provides direct contact of the antibiotic with the offending organism. Wound irrigation can be done through the window of a cast to clean the wound. A portable device can administer a high concentration of oxygen by hyperbaric therapy, which increases tissue perfusion for patients with chronic unremitting osteomyelitis. Systemic antibiotics are administered for more than 3 months to control the infection. A clean technique is preferred over strict aseptic technique to change dressings for contaminated (dirty) wounds.

The nurse observes warm and flushed skin over the pelvic region of a patient reporting pain in the pelvic region. The lab investigations reveal elevated serum alkaline phosphatase (ALP), serum uric acid, and urinary hydroxyproline levels. What does the nurse infer about the diagnosis?

Paget's disease The most common site of occurrence of Paget's disease is the region of hips and pelvis. The localized flushing and warmth is due to increased blood flow due to the formation of highly vascular, structurally weak bone. Paget's disease is characterized by elevated levels of serum ALP and urinary hydroxyproline. In osteoporosis, the ALP levels are not elevated. In osteomalacia and osteopetrosis, there is no hyper-perfusion (flushing of blood) in the region of pathology.

The nurse is caring for a patient with prostate cancer who has bone metastasis. The nurse anticipates that the health care provider will prescribe which medication?

Pamidronate Pamidronate is a bisphosphonate that is available intravenously and is approved for bone metastasis from the breast, lung, and prostate. Pamidronate protects bones and prevents fractures. Calcitonin is used for the treatment of postmenopausal osteoporosis, Paget's disease, and hypercalcemia associated with cancer. Medroxyprogesterone is indicated for treating menopausal symptoms and preventing osteoporosis. Tamsulosin hydrochloride is an alpha-adrenergic blocking agent used for the treatment of benign prostatic hyperplasia (BPH).

The patient complains to the nurse of acute pain in the 3rd and 4th toes and a burning sensation in the web space between these toes. Which condition would the nurse anticipate in the patient?

Plantar digital neuritis Plantar digital neuritis or Morton's neuroma occurs due to small tumor growth in the digital nerve of the foot. The patient usually experiences acute pain and a burning sensation in the web space. The pain involves the entire surface of the 3rd and 4th toes. A hammertoe is the dorsiflexion of the metatarsophalangeal joint with plantar flexion of the proximal interphalangeal joint next to it. A deformity of the great toe joint where the hallux is deviated medially away from the first metatarsal bone is called hallux valgus. Plantar fasciitis is an inflammation of plantar fascia located in the arch of the foot.

Which foot disorder is one of the most common causes of heel pain?

Plantar fasciitis Plantar fasciitis is one of the most common causes of heel pain. It involves pain and inflammation of a thick band of tissue, called the plantar fascia, which runs along the bottom of the foot and connects the heel bone to the toes. A callus is a thickened and hardened part of the skin or soft tissue, which usually forms in an area that has been subjected to friction. Morton's neuroma is an injury to the nerve between the toes, which causes pain. The injury is caused by the growth of a small tumor in a digital nerve of the foot. Hypertrophic ungual labium is chronic hypertrophy of the nail lip caused by improper nail trimming.

The nurse observes that a patient has an ingrown toenail that is hindering the patient's ambulation. What treatments does the nurse suggest for this patient? Select all that apply.

Soaking the foot in warm water Applying antibiotic ointment In an ingrown nail, the nail sliver penetrates the skin, resulting in inflammation that may hinder ambulation and interfere with activities of daily living. After the nail sliver is removed by a podiatrist, treatment involves soaking the foot in warm water and applying antibiotic ointment. Application of an ice pack is suitable for plantar fasciitis rather than an ingrown toenail. Treatment of secondary infection is advised in hypertrophic ungual labium, which results from an untreated ingrown nail. The application of padding and lanolin creams is recommended for calluses.

What is the primary role of the nurse when caring for an adult patient with muscular dystrophy (MD)?

Supportive care Management of the patient with MD is supportive and involves the entire health care team. Coordinating pain management is not the nurse's primary role for the adult patient with MD. The nurse's role does not focus on whether the patient keeps appointments; this would be more important for patients who, for example, are receiving intermittent chemotherapy. The nurse is always an advocate for all patients and families, but this is not the nurse's primary role when caring for the patient with MD.

A patient diagnosed with Dupuytren's contracture reports functional impairment of the right hand. What treatment is required to relieve his condition?

Surgical fasciectomy Functional impairment of an appendage is an advanced stage of Dupuytren's contracture; the only successful treatment is a limited or wide-awake fasciectomy. Splinting and physiotherapy are done as postoperative interventions. Radiation therapy is done in the initial stages of Dupuytren's contracture to prevent the disease progression; this therapy will not cure an existing condition.

A patient is prescribed the bisphosphonate (BP) alendronate for osteoporosis. What does the nurse teach the patient?

Take the medication early in the morning with 8 ounces of water. The patient who is prescribed alendronate must take the medication on an empty stomach with 8 ounces of water and wait for 30 to 60 minutes in an upright position, either sitting or standing, before eating or drinking. BPs are associated with esophageal ulcers, especially if the tablet is not swallowed completely. The medication is taken either daily or weekly depending on the dose. Patients with poor renal function, hypocalcemia, or gastroesophageal reflux disease (GERD) must not take BPs. Patients receiving BP therapy by IV need not have a liver function test before starting the medication; however, they must have an oral assessment and preventive dentistry before beginning therapy because this therapy is associated with jaw osteonecrosis.

Which finding does the nurse expect to observe in a patient with suspected common chronic osteomyelitis?

Ulceration of the skin Ulceration of the skin is a feature of chronic osteomyelitis. Erythema of the affected area; fever; and constant, localized, pulsating bone pain are features of acute osteomyelitis.

Which is the best way to decrease the risk for osteoporosis in a patient who has just been diagnosed with the disease?

Walk for 30 minutes three times a week Walking for 30 minutes three to five times a week is the single most effective exercise for osteoporosis prevention. Walking is a safe way to promote weight-bearing and muscle strength. A variety of nutrients are needed to maintain bone health, so the promotion of a single nutrient will not prevent or treat osteoporosis. High-impact exercise and overtraining such as running may cause vertebral compression fractures and should be avoided. Calcium loss occurs at a more rapid rate when intake of phosphorus is high; people who drink large amounts of carbonated beverages each day (over 40 ounces) are at high risk for calcium loss and subsequent osteoporosis, regardless of age or gender.

What teaching does the nurse provide to a patient who had outpatient surgery for hallux valgus?

Wear an orthopedic boot or shoe Partial weight-bearing will be allowed when the patient wears an orthopedic boot or shoe. The healing time after surgery is about 6 to 12 weeks; the feet receive less blood flow as compared to the other parts of the body because of their distance from the heart. Management of Morton's neuroma includes surgical removal of the neuroma and application of a pressure dressing.

The nurse is taking the history of an adult female patient. Which factor places the patient at risk for osteoporosis?

Working at a desk and playing the piano for a hobby Sedentary lifestyle and prolonged immobility produce rapid bone loss. The patient would have to consume large amounts of carbonated beverages daily (over 40 ounces) for this to be a risk factor for osteoporosis. Maintaining estrogen levels reduces the risk for osteoporosis. Alcohol has a direct toxic effect on bone tissue, resulting in decreased bone formation and increased bone resorption. For those who have excessive alcohol intake, alcohol calories decrease hunger and the need to take in adequate quantities of nutrients. This patient's alcoholic intake is not high, so it is not a risk factor.