CH. 68 MUSCULOSKELETAL DISORDERS

4. A nurse is providing an educational class to a group of older adults at a community senior center. The topic of the class is nutrition. The nurse informs the group that the recommended adequate intake (RAI) level of calcium daily is what? A) 1000 mg B) 1100 mg C) 1200 mg D) 1300 mg

1200 MG **The RAI level of calcium for adults 51 years of age and older is 1200 mg per day. The RAI level of calcium for ages 9 to 19 years of age is 1300 mg per day. The RAI level for adults 19 to 50 years of age is 1000 mg per day.

30. A 72-year-old woman is admitted to the orthopedic unit with a possible diagnosis of osteoporosis. Routine x-rays have been ordered. As the nurse caring for the patient, you know that osteoporosis may be undetectable on routine x-rays until there has been demineralization to what extent? A) 15% to 30% B) 25% to 40% C) 35% to 50% D) 45% to 60%

25%-40% ** Osteoporosis may be undetectable on routine x-rays until there has been 25% to 40% demineralization, resulting in radiolucency of the bones. Therefore options A, C, and D are incorrect.

8. You are assisting with assessments on a group of medical-surgical patients. What patient do you recognize as being at the highest risk for the development of osteomyelitis? A) A middle-age adult who takes ibuprofen daily for rheumatoid arthritis B) An elderly patient with an infected pressure ulcer in the sacral area C) A 17-year-old football player who had orthopedic surgery 6 weeks prior D) An infant diagnosed with jaundice

AN ELDERLY PATIENT WITH AN INFECTD PRESSURE ULCER IN THE SACRAL AREA **Patients who are at high risk of osteomyelitis include those who are poorly nourished, elderly and obese. The elderly patient with an infected sacral pressure ulcer is at the greatest risk for the development of osteomyelitis, as this patient has two risk factors: age and the presence of a soft tissue infection that has the potential to extend into the bone. The patient with rheumatoid arthritis has one risk factor, the arthritis. The infant with jaundice has no identifiable risk factors. The patient 6 weeks post-surgery is beyond the window of time for the development of a postoperative surgical wound infection.

7. A nurse, caring for a patient with Paget's disease, is analyzing her patient's laboratory values. Which of the following values is most often seen in a patient with Paget's disease? A) An elevated serum alkaline phosphatase level and elevated serum calcium levels B) A low serum alkaline phosphatate level and a low serum calcium level C) An elevated serum alkaline phosphatase level and a normal serum calcium level D) A normal serum alkaline phosphatase level and a low serum calcium level

AN ELEVATED SERUM ALKALINE PHOSPHATASE LEVEL AND A NORMAL SERUM CALCIUM LEVEL **Patients with Paget's disease have normal blood calcium levels. Elevated serum alkaline phosphatase concentration and urinary hydroxyproline excretion reflect the increase osteoblastic activity associated with this condition.

21. Patients who suffer from Paget's disease have more than one pharmacologic option to treat their disease process. What type of drug is the drug of choice for Paget's disease? A) Antineoplastic B) Antirheumatoid C) Anticholinergic D) Antiosteoclastic

ANTIOSTEOCLASTIC **Patients with moderate to severe disease may benefit from specific antiosteoclastic therapy. Several medications reduce bone turnover, reverse the course of the disease, relieve pain, and improve mobility. Antineoplastic drugs are used in chemotherapy; antirheumatoid drugs are used to fight rheumatoid arthritis; and anticholinergic drugs block the effects of the neurotransmitter acetylcholine.

1. The nurse is caring for a 35-year-old man diagnosed with a back strain. What would be important to discuss with this patient? A) Avoid lifting more than one-third of his body weight without assistance. B) Focus on using back muscles during lifting. C) Lift objects while holding the object away from the body. D) Tighten the abdominal muscles and lock the knees during the lifting of an object.

AVOID LIFTING MORE THAN ONE-THIRD OF HIS BODY WEIGHT WITHOUT ASSISTANCE **The nurse will instruct the patient on the safe and correct way to lift objects—using the strong quadriceps muscles of the thighs, with minimal use of the weak back muscles. To prevent recurrence of acute low back pain, the nurse may instruct the patient to avoid lifting more than one-third of his weight without help. The patient should be informed to place the feet a hip-width apart to provide a wide base of support, the person should bend the knees, tighten the abdominal muscles, and lift the object close to the body with a smooth motion, avoiding twisting and jerking.

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

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

13. Studies for pre-nursing students include the anatomy and physiology of the human body. What hormone do the students learn inhibits bone resorption and promotes bone formation? A) Estrogen B) Parathyroid C) Calcitonin D) Progesterone

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

36. You are precepting a new graduate nurse who has just started working on the orthopedic unit. Today the two of you are providing care for a patient who has just returned from having foot surgery with percutaneous pins. The graduate nurse is discussing the potential for infection in patients who undergo foot surgery. What would you tell the graduate nurse about the potential for infection? A) Dressing changes are done under strict sterile technique. B) Surgical site can be soaked in hot bath water for up to 10 minutes. C) Use soap and clorox to clean pin sites. D) Care must be taken to protect the surgical wound from dirt and moisture.

CARE MUST BE TAKEN TO PROTECT THE SURGICAL WOUND FROM DIRT AND MOISTURE **Any surgery carries a risk of infection. In addition, percutaneous pins may be used to hold bones in position, and these pins serve as potential sites for infection. Care must be taken to protect the surgical wound from dirt and moisture. When bathing, the patient can secure a plastic bag over the dressing to prevent it from getting wet. Patient instructions concerning aseptic wound care and pin care may be necessary. You would not use Clorox to clean the pin sites.

11. A female patient tells the nurse that she has pain and numbness to her thumb, first finger, and second finger of the right hand. The nurse discovers that the patient is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the patient could possibly have what? A) Carpel tunnel syndrome B) Tendonitis C) Impingement syndrome D) Dupuytren's contracture

CARPEL TUNNEL SYNDROME **Carpel tunnel syndrome may be manifested by numbness, pain, paresthesia, and weakness along the median nerve. Tendonitis is inflammation of muscle tendons. Impingement syndrome is a general term that describes all lesions that involve the rotator cuff of the shoulder. Dupuytren's contracture is a slowly progressive contracture of the palmar fascia.

6. The nursing instructor is discussing osteomalacia with her nursing students. The instructor gives the student the assignment of planning a day's menu for a patient with osteomalacia. What would be the best choice for breakfast for a patient with osteomalacia? A) Cereal with milk, a scrambled egg, and grapefruit B) Fresh fruit with granola sprinkled on the fruit C) Waffles with fresh strawberries and powdered sugar D) A bagel topped with vegetable cream cheese and a side dish of grapes

CEREAL WITH MILK, A SCRAMBLED EGG, AND GRAPEFRUIT **The nursing instructor will teach the students that the best meal option is the one that contains the highest dietary sources of calcium and vitamin D. The best selection is cereal with milk, and eggs, as these foods contain calcium and vitamin D in a higher quantity over the other menu options.

29. A patient diagnosed with osteoporosis has bones that become progressively porous, brittle, and fragile; they fracture easily under stresses that would not break normal bone. This increased susceptibility to fractures manifest most commonly as what? A) Fractured tibias B) Dislocated shoulders C) Boxer's fractures D) Compression fractures of the spine

COMPRESSION FRACTURES OF THE SPINE **These increase susceptibility to fracture, which occur most commonly as compression fractures of the thoracic and lumbar spine, hip fractures, and Colles' fractures of the wrist. Osteoporosis does not generally manifest as fractured tibias, dislocated shoulders or boxers fractures.

16. A patient has returned to the unit after undergoing limb-sparing surgery to remove a bone tumor. The nurse providing postoperative care assesses for what complication from surgery? A) Nutritional deficiency B) Delayed wound healing C) Loss of body weight D) Pathologic fractures

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

27. A patient presents at the clinic stating they have hallux valgus. What signs and symptoms would the nurse expect this patient to manifest? A) Deviation of a great toe laterally B) A great toe pulled in an upward position C) An abnormally high arch of the foot D) A diminished longitudinal arch of the foot

DEVIATION OF A GREAT TOE LATERALLY **A deformity in which the great toe deviates laterally and there is a marked prominence of the medial aspect of the first metatarsal-phalangeal joint and exostosis is referred to as hallux valgus (bunion). Hammer toe is a flexion deformity of the interphalangeal joint, which may cause the toe to be pulled upward. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. A diminished longitudinal arch of the foot is referred to a flatfoot or pes planus.

26. A 54-year-old male patient presents at the clinic with complaints of a dull aching discomfort, morning numbness, cramping, and stiffness in their fourth and fifth fingers. What disease process would the nurse suspect? A) Tendonitis B) A ganglion C) Carpal tunnel syndrome D) Dupuytren's disease

DUPUYTREN'S DISEASE **The patient may experience dull aching discomfort, morning numbness, cramping, and stiffness in the affected fingers. This condition starts in one hand, but eventually both hands are affected. The scenario does not describe tendonitis, a ganglion, or carpal tunnel syndrome.

17. The nurse is caring for a patient who is 12 hours postop from foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure will the nurse implement to control the edema? A) Elevate the foot on several pillows. B) Apply warm compresses intermittently to the surgical area. C) Administer a diuretic. D) Increase circulation through frequently ambulation.

ELEVATE THE FOOT ON SEVERAL PILLOWS **To control the edema in the foot of a patient who experienced foot surgery, the nurse will elevate the foot on several pillows when the patient is sitting or lying. Diuretic therapy is not an appropriate intervention for edema related to inflammation. Intermittent ice packs should be applied to the surgical area during the first 24 to 48 hours after surgery to control edema and provide some pain relief. Ambulation will gradually be resumed based upon the guidelines provided by the surgeon.

3. A 42-year-old man presents at the clinic complaining of pain in his heel so bad it inhibits his ability to walk. The patient is diagnosed with plantar fasciitis. Patient teaching provided by the nurse would include what instructions to decrease the pain associated with this condition? A) Wrapping the affected area in lamb's wool or gauze B) Gently stretching the foot and the Achilles tendon C) Wearing open-toed shoes D) Application of keratolytic ointment

GENTLY STRETCHING THE FOOT AND THE ACHILLES TENDON **Plantar fasciitis leads to pain that is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon.

19. The Nursing Instructor is talking with her clinical group about osteomalacia. What would the instructor teach her students about a patient with osteomalacia who is being treated with vitamin D supplements and their risk for what? A) Hypocalcemia B) Hypernatremia C) Hypermagnesemia D) Hypochloremia

HYPOCALCEMIA **Laboratory studies show low serum calcium, low phosphorus levels, and elevated alkaline phosphatase levels.

2. The nurse is discussing conservative management of tendonitis with a patient. Which of the following may be an effective approach to managing tendonitis? A) Weight reduction B) Stress reduction C) Intermittent application of ice and heat to the affected joint D) Range of motion of the affected joint

INTERMITTENT APPLICATION OF ICE AND HEAT TO THE AFFECTED JOINT **Conservative management of tendonitis includes rest of the extremity, intermittent ice and heat to the joint, and nonsteroidal anti-inflammatory drugs to control the inflammation and pain. Weight reduction, stress reduction, and range-of-motion exercises are not part of conservative management of tendonitis.

14. A patient has been admitted to the orthopedic unit with a suspected diagnosis of osteomalacia. The nurse expects to find which of the following laboratory study results to be present? A) High serum calcium and low phosphatase level B) High serum calcium and high phosphatase level C) Low serum calcium and high phosphorus level D) Low serum calcium and low phosphorus level

LOW SERUM CALCIUM AND LOW PHOSPHORUS LEVELS **Laboratory studies will reveal a low serum calcium and low phosphorus level. Therefore options A, B, and C are incorrect.

12. A clinic nurse is admitting a patient who reports a throbbing burning feeling in the right foot during the day but notes that the pain is relieved with rest. What might the nurse suspect the patient may have? A) Morton's neuroma B) Pes cavus C) Hallux valgus D) Onychocryptosis

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

24. The emergency department nurse is caring for a patient who has presented with complaints of back pain. What would be the most appropriate diagnostic test to detect degenerative disk or disk protrusions? A) Myelogram B) Bone scan C) Epidural venogram D) Electromyogram

MYELOGRAM **The most appropriate diagnostic test to detect degenerative disk or disk protrusions is the myelogram. A bone scan is used to disclose infections, tumors, and bone marrow abnormalities. An electromyogram is used to evaluate spinal nerve root disorders (radiculopathies). Epidural venography is a simple and safe procedure for the diagnosis of herniated intervertebral disk and other disease of the epidural space.

38. A patient has come to the clinic for a routine annual physical. The Nurse Practitioner notes a large projection of bone at the shoulder. The Nurse Practitioner knows that this is most likely what? A) An osterosarcoma B) An osteochondroma C) An osteoblast D) An osteitis

OSTEOCHONDROMA **Osteochondroma is the most common benign bone tumor. It usually occurs as a large projection of bone at the end of long bones (at the knee or shoulder). It develops during growth and then becomes a static bony mass. Osteosarcoma (ie, osteogenic sarcoma) is the most common and most often fatal primary malignant bone tumor. Osteoblastic activity lays down new bone.

15. An 80-year-old man in a long-term care facility has a chronic leg ulcer. When the Nurse Practitioner makes his rounds, the man states that the area has become increasingly painful. The Nurse Practitioner assesses the area and notes that the wound bed of the ulcer is unchanged, but the site is now swollen and warm to the touch. The Nurse Practitioner notifies the physician of these symptoms as the patient may have developed what? A) Osteomyelitis B) Osteoporosis C) Osteomalacia D) Infectious arthritis

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

35. A 39-year-old diabetic patient is at the clinic having a foot check done by the nurse. The nurse notes that the patient's right foot is pale and mottled, cool to touch, with a capillary refill of > 3 seconds. What would the nurse suspect the patient has? A) Hematogenous osteomyelitis B) Osteomyelitis with vascular insufficiency C) Contiguous-focus osteomyelitis D) Osteomyelitis with muscular deterioration

OSTEOMYELITIS WITH VASCULAR INSUFFICIENCY **Osteomyelitis is classified as hematogenous osteomyelitis (ie, due to blood-borne spread of infection); contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury (eg, gunshot wound); and osteomyelitis with vascular insufficiency, seen most commonly among patients with diabetes and peripheral vascular disease, most commonly affecting the feet. Osteomyelitis with muscular deterioration is a detractor for this question.

37. You are preparing a patient who underwent foot surgery for discharge. You are discussing the use of assistive devices for a portion of your rehabilitation with the patient and their family. What does the choice of assistive devices depend on? A) Patient's general condition, balance, and weight-bearing prescription B) Patient's general condition, strength, and weight restrictions C) Patient's motivation, balance, and weight-bearing prescription D) Patient's weight-bearing prescription, motivation, and balance

PATIENT'S GENERAL CONDITION, STRENGTH, AND WEIGHT RESTRICTIONS **Assistive devices (eg, crutches, walker) may be needed. The choice of the devices depends on the patient's general condition and balance and on the weight-bearing prescription. The patient's strength, motivation, and weight restrictions are not what the choice of assistive devices is based on.

28. A patient with foot problems is diagnosed with Charcot-Marie-Tooth disease. What manifestation would you expect the patient to manifest with Charcot-Marie-Tooth disease? A) Pes cavus B) Hallux valgus C) Morton's neuroma D) Onychocryptosis

PES CAVUS **Charcot-Marie-Tooth disease and diabetes are common causes of pes cavus. A hallux valgus is commonly called a bunion. Morton's neuroma (plantar digital neuroma, neurofibroma) is a swelling of the third (lateral) branch of the median plantar nerve. Onychocryptosis is an ingrown toenail.

33. What is the drug of choice used to treat osteomyelitis? A) Calcitonin B) Mithracin C) Alkaline phosphatase D) Potassium hydrochloride

POTASSIUM HYDROCHLORIDE **Calcitonin therapy facilitates remodeling of abnormal bone into normal lamellar bone, relieves bone pain, and helps alleviate neurologic and biochemical signs and symptoms.

20. A patient presents to the free clinic complaining of a leg ulcer that isn't healing. A culture is taken from the wound site, which is found to be caused by osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is what? A) Staphylococcus aureus B) Proteus C) Pseudomonas D) Escherichia coli

S. AUREAUS ** S. aureus causes over 50% of bone infections. Proteus, Pseudomonas, and E. coli are also causes, but to a lesser extent. This makes options B, C, and D incorrect.

10. A patient presents at the clinic complaining of back pain that goes all the way down the back of the leg to the foot. What is this type of pain referred to as? A) Bursitis B) Radiculopathy C) Sciatica D) Tendonitis

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

5. The nurse is providing a class on osteoporosis at the local senior citizens center. Which of the following statements related to osteoporosis is correct? A) Osteoporosis is a disease of the elderly. B) A non-modifiable risk factor for osteoporosis is a person's level of activity. C) Secondary osteoporosis occurs in women after menopause. D) Slow discontinuation of your corticosteroid therapy will halt the progression of the osteoporosis, but not restore the lost bone mass.

SLOW DISCONTINUATION OF YOUR CORTICOSTERIOD THERAPY WILL HALT THE PROGRESSION OF THE OSTEOPOROSIS, BUT NOT RESTORE THE LOST BONE MASS. **When corticosteroid therapy is discontinued, the progression of osteoporosis is halted, but restoration of lost bone mass does not occur. Osteoporosis is not a disease of the elderly because its onset occurs earlier in life, when bone mass peaks and then begins to decline. A person's level of physical activity is a modifiable factor that influences peak bone mass. Lack of activity increases the risk for the development of osteoporosis. Primary osteoporosis occurs in women after menopause.

31. When discussing diseases of the bone with his nursing students the nursing instructor gives the students a list of risk factors for osteoporosis. What risk factors should be included in that list? A) Mobility B) Lap-banding surgery C) Small-framed, nonobese Caucasian women D) A diet high in calcium and vitamin D

SMALL-FRAMED, NON-OBESE, CAUCASIAN WOMEN ** Small-framed, nonobese Caucasian women are at greatest risk for osteoporosis. Also, Asian women of slight build are at risk for low peak BMD. African-American women, who have a greater bone mass than Caucasian women, are less susceptible to osteoporosis. Other risk factors include immobility, bariatric bypass surgery, and diets that are not rich in calcium and vitamin D.

25. A 32-year-old patient comes to the clinic complaining of shoulder tenderness, pain, and limited movement. Upon assessment the nurse finds edema. An MRI shows hemorrhage of the rotator cuff tendons. The patient is diagnosed with what stage impingement syndrome? A) Stage I B) Stage II C) Stage III D) Stage IV

STAGE 1 Stage I impingement syndrome is characterized by edema and hemorrhage of the rotator cuff tendons or subacromial bursa. The patient experiences pain, shoulder tenderness, limited movement, muscle spasm, and eventual atrophy. The process may progress to a partial or complete rotator cuff tear (referred to as Stage II or Stage III impingement syndrome, respectively). Stage IV is a distractor for this question.

9. The nurse is caring for a patient with a bone tumor. The nurse provides education that teaches the patient to implement measures to reduce the risk for pathologic fractures. What intervention will assist the patient in fracture prevention? A) Strive to achieve the maximum weight-bearing capabilities. B) Instruct the patient to strengthen the affected muscles through weight training. C) Support the affected extremity with external supports (splints). D) Limit the use of reliance of on assistive devices.

STRIVE TO ACHIEVE THE MAX WEIGHT-BEARING CAPABILITIES **During nursing care, the affected extremities must be supported and handled gently. External supports (splints) may be used for additional protection. Prescribed weight-bearing restrictions must be followed. Assistive devices should be used to strengthen the unaffected extremities.

34. The health care team is caring for a patient with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What is the usual treatment for osteomalacia cause by malabsorption? A) Supplemental calcium and increased doses of vitamin D B) Supplemental calcium and increased doses of vitamin E C) Supplemental potassium and increased doses of vitamin D D) Supplemental potassium and increased doses of vitamin E

SUPPLEMENTAL CALCIUM AND INCREASED DOSES OF VITAMIN D **If osteomalacia is caused by malabsorption, increased doses of vitamin D, along with supplemental calcium, are usually prescribed

32. A nurse is presenting her research on osteomalacia at an international conference. When would the nurse tell the attendees that an osteotomy may be performed? A) When a cure would be effected B) When persistent infection is evident C) To correct long bone deformity D) With persistent orthopedic deformities

TO CORRECT LONG BONE DEFORMITY **Long-term monitoring of the patient is appropriate to ensure stabilization or reversal of osteomalacia. Some persistent orthopedic deformities may need to be treated with braces or surgery (eg, osteotomy may be performed to correct long bone deformity). Therefore, options A, B, and D are incorrect.

22. A nurse is caring for a patient who has been hospitalized with complaints of low back pain. The patient is scheduled for diagnostic testing in the morning. What is a diagnostic test for low back pain? A) Electroencephalogram B) Arteriogram C) ABG D) Ultrasound

ULTRASOUND **An ultrasound is one diagnostic test that can be used performed on patients experiencing low back pain.

18. A 36-year-old diabetic woman is attending a class on the prevention of associated diseases. When the nurse talks about osteoporosis, the woman asks the nurse what steps she may take to prevent osteoporosis. What should the nurse advise her to do? A) Include adequate intake of vitamin E. B) Walk 20 to 30 minutes 3 days a week. C) Engage in isometric exercises 20 to 30 minutes 3 days a week. D) Include an average daily intake of 300 mg of calcium.

WALK 20-30 MIN 3 DAYS A WK **Exercise should include activities such as walking, which provide the stress of weight and muscle activity. This enhances bone formation. Average daily intake of calcium for a 36-year-old is 1000 mg/d.

23. You are providing an educational class for a group of patients who suffer from low-back pain. What would you include as major goals for patients who have low back pain? A) Improved pain detection B) Use of back-muscle techniques C) Improved self-satisfacton D) Weight reduction

WEIGHT REDUCTION **The major nursing goals for the patient may include relief of pain, improved physical mobility, use of back-conserving techniques of body mechanics, improved self-esteem, and weight reduction (as necessary).