Patho 7 Musculoskeletal Health Problems

Which of the following laboratory values is most significant to the nurse when assessing a client for complications associated with Paget's disease? 1. Calcium level of 15 mg/dL 2. Positive rheumatoid factor (RF) 3. Blood urea nitrogen (BUN) of 90 mg/dL 4. Eosinophil sedimentation rate (ESR) of 30 mm/h

1. Calcium level of 15 mg/dL Hypercalcemia can occur as a complication of Paget's disease secondary to increased osteoclast activity. The other tests are not specific to Paget's disease although they are all abnormal values. Find the laboratory test result that reflects the abnormal bone reabsorption and formation seen in Paget's disease.

The nurse is explaining osteoarthritis (OA, or degenerative joint disease) to a client. The nurse incorporates which information about the underlying pathology in the discussion? 1. Changes in composition of the articular cartilage contribute to increased friction during joint movement 2. Joint inflammation occurs secondary to the presence of immune complexes within the joint cavity 3. Excessive bone necrosis within the joint occurs secondary to increased osteoclastic activity 4. Bone damage occurs secondary to osteolysis and excessive bone remodeling

1. Changes in composition of the articular cartilage contribute to increased friction during joint movement Articular cartilage is responsible for decreasing friction during joint movement and displacing the force of the workload onto the subchondral bone. In osteoarthritis (OA), the composition of the articular cartilage is changed because of a malfunction in the release of cytokines and proteases. Consequently, the articular cartilage can no longer perform its original function. The pathology does not involve immune complexes, excessive bone necrosis or osteolysis, and extensive bone remodeling. Eliminate the options that describe other diseases. Another clue lies in the other name for the disease.

The nurse is caring for a client who had a cast applied to immobilize a tibia fracture that occurred 6 hours ago. The client reports severe leg pain that is unrelieved by the opioid analgesic. The nurse suspects that what cycle of events may be causing compartment syndrome and jeopardizing the limb? 1. Increased pressure within tissues results from excessive edema at fracture site, compressing the vascular network. 2. Nerves are damaged by trauma, and narcotics will not relieve pain. 3. Peripheral pulses will become accelerated to compensate for inadequate oxygen supply to injured tissue. 4. Injured fascia is elastic and expands with fluid so the cast becomes too tight, causing pain and compromising circulation.

1. Increased pressure within tissues results from excessive edema at fracture site, compressing the vascular network. Edema is expected immediately following a fracture, but because the fascia is nonelastic, excessive swelling will lead to increased capillary pressure within the area, resulting in nerve and muscle damage if left untreated. Damage is irreversible if the capillary pressure reaches 30 mmHg. A pulse may still be present during early stages of compartment syndrome. One factor that can differentiate pain associated with trauma from the fracture and that from compartment syndrome is the ineffectiveness of analgesics when compartment syndrome occurs. Consider the hemorrhage and edema that occur at a fracture site and use the process of elimination to make a selection.

An adult client is being treated in the early stages of rheumatoid arthritis (RA). Which of the following drugs would the nurse expect to be included in the client's drug regime? Select all that apply. 1. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) or aspirin 2. Systemic corticosteroids such as prednisone (Deltasone) 3. Disease-modifying anti-rheumatoid drugs (DMARDs) such as methotrexate (Trexall) 4. Oral opioid analgesics such as oxycodone (Oxycontin) 5. Routine injections of an opioid such as morphine sulfate

1. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) or aspirin 3. Disease-modifying anti-rheumatoid drugs (DMARDs) such as methotrexate (Trexall) Disease-modifying anti-rheumatoid drugs (DMARDs) are now being used earlier in the treatment regime for rheumatoid arthritis (RA) because evidence suggests that they may play a role in arresting the disease process. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in combination with this drug classification for pain management. Systemic corticosteroids are not used until NSAIDs are no longer effective because of the severe side effects associated with their use. Opioid analgesics are not indicated early in the disease process. Note the clue words early stages in the stem. With this in mind, select agents that are useful to the disease process and analgesics that are milder in nature.

The nurse who is taking a medication history in a client with systemic lupus erythematosus (SLE) makes special note of the client's use of which drug? 1. Procainamide (Procan SR) 2. Acetylsalicylic acid (aspirin ASA) 3. Diazepam (Valium) 4. Azatoprine (Imuran)

1. Procainamide (Procan SR) Although the etiology of systemic lupus erythematosus (SLE) is unknown, certain environmental factors have been associated with the onset of symptoms. The administration of procainamide (Procan SR), an antidysrhythmic, and hydralazine (Apresoline), an antihypertensive, have been associated with SLE symptoms, which usually subside after the drug is discontinued. The core issue of the question is knowledge of which drugs have adverse effects resembling systemic lupus erythematosus (SLE). Use this knowledge and the process of elimination to make a selection.

To prevent occurrences of Raynaud's phenomenon, what instruction should the nurse give to a client diagnosed with systemic sclerosis (scleroderma)? 1. Wear gloves if the temperature is cold. 2. Perform range-of-motion (ROM) exercises weekly. 3. Limit sodium intake. 4. Avoid warm temperatures.

1. Wear gloves if the temperature is cold. Systemic sclerosis is characterized by functional and structural abnormalities of small arteries that lead to progressive vessel obstruction. Initial manifestations are usually noted in the skin, which thickens. Arthralgias and Raynaud's phenomenon are common early manifestations of systemic sclerosis. Attacks are usually triggered by cold temperatures. Clients with scleroderma should perform range of movement exercises daily, and avoid cold temperatures. Limiting sodium intake is not directly related to scleroderma. Recall that treatment is supportive to prevent vascular spasms due to cold temperatures. Identify options that are opposite and consider whether one of them may be the correct option.

The nurse is explaining the pathophysiology of osteoporosis to a female client. Which statement should the nurse include in the discussion to best describe the disease process? 1. "Increased amounts of estrogen in postmenopausal women contribute to bone loss." 2. "There is an imbalance between formation of new bone and the absorption of existing bone." 3. "A decrease in blood supply to the bone results in bony necrosis or the death of bone cells." 4. "An invasion by a pathogen leads to infection and destruction of bone"

2. "There is an imbalance between formation of new bone and the absorption of existing bone." Osteoporosis is characterized by a decrease in the number and activity of osteoblasts that form new bone and an increase in number of osteoclasts that absorb bone. It is more prevalent in postmenopausal women with low levels of estrogen. Bony necrosis and pathogens are not involved. Eliminate the options that relate to other diseases.

An adult male limps into the ambulatory clinic reporting a red, hot, swollen joint in his great toe. The problem developed after a night of heavy alcohol use. He asks the nurse what caused his gout pain to return. The nurse formulates a response based on what underlying pathophysiology? 1. Increased immune complexes are deposited within the joint cavity 2. Alteration in purine metabolism results in hyperuricemia; alcohol consumption may trigger it 3. Excessive bone remodeling is secondary to increased levels of phosphorus, related to overeating 4. Presence of fibrous adhesions within bony cartilage causes pain and a limping gait

2. Alteration in purine metabolism results in hyperuricemia; alcohol consumption may trigger it The pathophysiology of gouty arthritis is related to overproduction or decreased excretion of uric acid in the primary form. Alteration in purine metabolism results in hyperuricemia; alcohol consumption may trigger it. The pathophysiology does not involve deposits of immune complexes, increased phosphorus, or fibrous adhesions. The critical words in the question are gout and alcohol. Use nursing knowledge and the process of elimination to make a selection.

A female client has breast cancer that has metastasized to the bones. The nurse would develop which goals of nursing care for this client? Select all that apply. 1. Treat primary cancer and prevent further metastasis 2. Control pain associated with the disease 3. Promote maximal function and mobility 4. Prevent pathological fracture 5. Prevent complications form hypercalcemia

2. Control pain associated with the disease 3. Promote maximal function and mobility 4. Prevent pathological fracture 5. Prevent complications form hypercalcemia Metastatic bone disease weakens the bones, predisposing the client to pathological fractures. The major symptom is pain. The goals are to prevent pathological fractures, maximize function, maintain mobility, and control pain as much as possible. Hypercalcemia occurs in 10% to 20% of clients with metastatic bone disease because of demineralization, so this may also need to be controlled. A nursing goal would not be to prevent further metastasis. Do not choose goals that are unrealistic.

The nurse considers that which clients seen in the ambulatory clinic are at high risk for developing an osteosarcoma? Select all that apply. 1. Male, age 34 2. Female, age 15 3. Male, age 52, history of Paget's disease 4. Male, age 58 5. Female, age 34, and pregnant

2. Female, age 15 3. Male, age 52, history of Paget's disease 4. Male, age 58 The incidence of osteosarcoma, the most commonly diagnosed primary bone tumor, peaks around puberty in both boys and girls with a slight preference for males. A secondary peak incidence occurs in the 50-60 year age group, primarily in individuals with a history of radiation therapy, malignancies, or Paget's disease of bone. Adult males and females of child-bearing age are less likely to develop osteosarcoma. If this question is difficult and you need to make an educated guess, note that one option stands out as different from the others.

A client diagnosed with gouty arthritis is receiving medications to treat an acute attack. What action by the nurse will facilitate the excretion of urates and help prevent uric acid renal calculi? 1. Include in a plan of care for a client with acute osteomyelitis? 2. Give liberal fluids as tolerated to maintain a daily urine output of 2,000 mL or more. 3. Ensure an intake of fluids that equals approximately 1,000 mL in 24 hours. 4. Keep client on bed rest with the affected joint elevated as much as possible.

2. Give liberal fluids as tolerated to maintain a daily urine output of 2,000 mL or more. A liberal fluid intake (to maintain a urine output of 2,000 mL or more daily) is recommended to reduce calculi formation and increase urate excretion. Alkalizing agents such as bicarbonate or citrate may also minimize uric acid stone formation; acidifying urine may be of some use in preventing urinary tract infection. Bed rest is indicated during an acute attack to rest the joint, but rest does not prevent renal problems. Utilize principles of fluid balance and renal excretion to answer the question. Critical words include facilitate and excretion. Identify options that are opposite in nature if the correct answer is unknown because one of these would have to be incorrect.

Which interventions should the nurse expect to include in a plan of care for a client with acute osteomyelitis? Select all that apply. 1. Apply heat compresses to affected area. 2. Immobilize affected area in functional position. 3. Administer opioid analgesics as ordered for severe pain. 4. Administer acetaminophen (Tylenol) as prescribed for mild pain. 5. Maintain strict hand hygiene practices.

2. Immobilize affected area in functional position. 3. Administer opioid analgesics as ordered for severe pain. 4. Administer acetaminophen (Tylenol) as prescribed for mild pain. 5. Maintain strict hand hygiene practices. Immobilizing the joint, providing analgesia for mild or severe pain, and maintaining strict hand hygiene practices are appropriate nursing interventions to manage pain and prevent the spread of infection for a client diagnosed with osteomyelitis. The application of heat is contraindicated because it can increase edema and pain in the affected area and spread bacteria through vasodilatation. Identify the actions that provide comfort and maintain function. These will be the correct options in the question.

A client is diagnosed with osteomyelitis involving the foot. The wound is draining, and dressing changes are being done daily or more often as needed. What is the nurse's highest priority at this time? 1. Maintaining adequate pain control 2. Implementing aseptic technique 3. Promoting adequate nutrition 4. Splinting the foot to prevent foot drop

2. Implementing aseptic technique Although all the items listed are important in the plan of care for the client diagnosed with osteomyelitis, maintaining aseptic technique and preventing the spread of infection is crucial to resolving the disease process. Maslow's hierarchy may identify adequate pain control as the highest priority, but infection is the cause of the pain, making infection the primary focus. Implementation of aseptic technique the highest priority. Think of what causes the problem and deal with that first in a question such as this.

The nurse would document which expected health history and physical assessment data findings on an adult client with rheumatoid arthritis (RA)? Select all that apply. 1. Heberden's nodes 2. Morning stiffness lasting longer than 30 minutes 3. Asymmetric joint swelling 4. Swan neck deformities 5. Weight loss, anorexia, fatigue, and weakness

2. Morning stiffness lasting longer than 30 minutes 4. Swan neck deformities 5. Weight loss, anorexia, fatigue, and weakness Swan neck deformities of the hand are classic deformities associated with rheumatoid arthritis (RA) secondary to the presence of fibrous connective tissue within the joint space. Clients with RA experience morning stiffness lasting from 30 minutes up to several hours. Systemic manifestations include weakness, fatigue, and weight loss. RA is characterized by symmetrical joint involvement. Heberden's nodes and morning stiffness lasting less than 30 minutes are characteristic of osteoarthritis. The core issue of the question is the ability to distinguish between rheumatoid arthritis (RA) and osteoarthritis (OA). Use nursing knowledge and the process of elimination to make a selection.

The nurse is counseling the parents of a child diagnosed with muscular dystrophy (MD). Which statement by the nurse most accurately describes the disease progression? 1. "Prognosis is favorable with early detection" 2. "With aggressive physical therapy and the use of a walker, your child will remain ambulatory through adulthood" 3. "The muscles and the lungs may also become involved, and this can shorten your child's life span" 4. "Muscle weakness is progressive and rapid and your child will most likely be confined to a wheelchair by the age of 5"

3. "The muscles and the lungs may also become involved, and this can shorten your child's life span" Symptoms of muscular dystrophy (MD) usually manifest in early childhood. The child has a waddling gait and experiences frequent falls. There is no cure for the disease and muscles become progressively weaker. Most children are wheelchair confined by the teen years. As the disease progresses, heart and lung muscle are affected, resulting in cardiac and pulmonary failure. The child lives, on average, 15 years after onset. Recall that this is a progressive disease and the options are linear. Use this information and the process of elimination to make a selection.

A client viewing x-rays of a healing bone fracture asks the nurse if the bone will ever be normal again. The nurse's response will be based on knowledge of which events in the remodeling phase of bone healing? 1. Callus formation occurs. 2. Callus is replaced with mature bone. 3. Osteoclasts resorb excess callus to return the bone to its original shape. 4. Proliferation of osteoblast and fibroblasts occurs within the hematoma at the fracture site.

3. Osteoclasts resorb excess callus to return the bone to its original shape. During earlier stages of bone healing, overproduction of callus enlarges the bone and acts as a splint. Callus is eventually replaced with mature bone during the ossification phase of bone healing, and then the excess callus is resorbed during the remodeling phase to return the bone to its original shape. Apply principles of healing. Recall that remodeling is the last stage.

A client has had a fracture reduced and immobilized. Which of the following is a priority for assessment by the nurse to detect a classic hallmark manifestation of compartment syndrome as a complication? 1. Assessing for edema at the fracture side 2. Palpation of a pulse distal to the fracture site 3. Performing a pain assessment 4. Assessing for the presence of a drainage on the cast

3. Performing a pain assessment Compartment syndrome usually develops within the first 48 hours of injury, when edema is at its peak. Early manifestations include pain and normal or decreased peripheral pulse. The nurse should assess for edema, pulses, and presence of drainage as routine assessments; however, pain unrelieved by analgesics is a symptom most indicative of compartment syndrome. Identify the critical word priority in the stem of the question. With this in mind, expect all options to be plausible. Select the best one after reading all the options.

The nurse concludes that a client with osteoarthritis understood instructions on health maintenance if the client states that participation in which sport would be beneficial? 1. Tennis 2. Jogging 3. Swimming 4. Volleyball

3. Swimming Activities should be chosen that allow range of motion (ROM) but do not further injure a joint. Swimming is an aerobic exercise that does not stress the joints but allows full ROM. Weight-bearing exercises such as tennis, jogging, and volleyball place excessive strain on diseased joints and should not be activities of choice. Consider what activity is aerobic and puts less stress on damaged joints. The correct option stands out from the others.

The nurse interprets that which laboratory or diagnostic test data would be most significant in the client with Paget's disease? 1. Elevated white blood count (WBC) 2. Elevated erythrocyte sedimentation rate (ESR) 3. Positive tissue biopsy for Staphylococcus 4. Elevated serum alkaline phosphatase

4. Elevated serum alkaline phosphatase Serum alkaline phosphatase is elevated because of increased activity of bone cells. Inflammation is in the bone and usually does not reveal an elevated serum white blood cell count, erythrocyte sedimentation rate, or the presence of Staphylococcus. Choose the option that reflects loss of bone tissue. Eliminate the options related to infection.

In reviewing the medication order sheet for a client with systemic sclerosis (scleroderma), the nurse concludes that the ordered calcium channel blocker and alpha-adrenergic blocker are being given to treat which of the following problems accompanying this disease? 1. Renal failure 2. Pericarditis 3. Bradycardia 4. Raynaud's phenomenon

4. Raynaud's phenomenon When clients with scleroderma develop Raynaud's phenomenon, which is characterized by vasospasms of the arteries and veins of the hands, calcium channel blockers (such as nifedipine) or alpha-adrenergic blockers (such as prazosin) are the treatment of choice. Angiotensin-converting enzyme (ACE) inhibitors would be used for renal involvement. Bradycardia is not specific to scleroderma. Clients may experience pericarditis, but this is not treated with calcium channel or alpha adrenergic blockers. Recognize that all the options are possible concerns for a client with scleroderma. Consider which complication may be treated with the drugs in the stem of the question.