Patho FINAL Prep U Chapter 43

The nurse knows that which of the following patients listed below is at high risk for developing a hip fracture? a. 77 year old male who runs marathons and maintains a BMI of 25. b. 82 year old female with macular degeneration and uses a walker to go to the bathroom. c. 64 year old male with uncontrolled diabetes and chronic kidney disease on dialysis. d. 73 year old nursing home patient with long-term continence issues but able to walk the hallways for exercise.

Correct response: 82 year old female with macular degeneration and uses a walker to go to the bathroom. Explanation: Hip fracture is a major public health problem in the Western world. The incidence of hip fractures increases with age. The incidence is also higher in white women compared with nonwhite women. Risk factors for hip fracture include low BMI, tall body structure, use of benzodiazepines, lack of exercise, previous injury to lower body extremity, vision problems, and confusion.

Which person is most at risk for hip fractures? a. 66-year-old Caucasian female with history of alcoholism b. 70-year-old active African-American woman c. 26-year-old female volleyball player d. 50-year-old Asian male with dementia

Correct response: a. 66-year-old Caucasian female with history of alcoholism Explanation: Risk factors for hip fracture include physical inactivity, excessive consumption of alcohol, use of certain psychotropic drugs, residence in an institution, visual impairment, and dementia.13 Osteoporosis is an important contributing factor.

A patient has been admitted with a fractured pelvis that occurred in an auto accident just a few hours ago. The nurse has noticed a slight change in behavior. Which of the following clinical manifestations would lead the nurse to suspect the patient has fat emboli that has migrated? Select all that apply. a. Complaints of substernal chest pain. b. Complaints of pain in the lower abdomen and back. c. Pulse rate 120 with temperature of 99.70. d. Profuse diaphoresis with pallor noted. e. Urine output of 30 mL/hour.

Correct response: a. Complaints of substernal chest pain. c. Pulse rate 120 with temperature of 99.70. d. Profuse diaphoresis with pallor noted. Explanation: Initial symptoms of FES are a subtle change in behavior and signs of disorientation resulting from emboli in the cerebral circulation combined with respiratory depression. There may be complaints of substernal chest pain and dyspnea accompanied by tachycardia and low-grade fever. Diaphoresis, pallor, and cyanosis become evident as respiratory function deteriorates. It would be expected that the patient have lower abdominal and back pain since they have a pelvic fracture. The normal urine output is a minimum of 30 mL/hour.

A client who was involved in an automobile accident experienced major trauma and sustained a fractured femur. The nurse notices the following changes 4 hours after admission to the critical care unit: • Disorientation • Dyspnea • Tachycardia • Low-grade temperature • Diaphoresis • Substernal chest pain The nurse suspects: a. Fat embolism syndrome (FES) b.Sympathetic nervous system response c. Parasympathetic nervous system response d. Autonomic hyperreflexia

Correct response: a. Fat embolism syndrome (FES) Explanation: The main clinical features of FES are respiratory failure, cerebral dysfunction, and skin and mucosal petechiae. Cerebral manifestations include encephalopathy, seizures, and focal neurologic deficits unrelated to head injury. Initial symptoms begin within a few hours to 3 to 4 days after injury and include a subtle change in behavior and signs of disorientation resulting from emboli in the cerebral circulation combined with respiratory depression. There may be complaints of substernal chest pain and dyspnea accompanied by tachycardia and a low-grade fever. Diaphoresis, pallor, and cyanosis become evident as respiratory function deteriorates. The other options would not have these manifestations.

The client with sickle cell disease is at risk for development of which bone complication? a. Osteonecrosis b. Osteomyelitis c. Benign neoplasms d. Complex regional pain syndrome (CRPS)

Correct response: a. Osteonecrosis Explanation: Osteonecrosis, or death of a segment of bone, is a condition caused by interuption of blood supply to the marrow, medullary bone, or cortex in the absence of infection. It is a common complication of sickle cell disease. Osteomyelitis represents an acute or chronic infection of the bone. Benign neoplasms of the bone and CRPS are not associated with sickle cell disease.

Which diagnoses increase the risk of osteonecrosis? Select all that apply. a. Rheumatoid arthritis b. Sickle cell disease c. Systemic lupus erythematosus d. Vasculitis e. Osteoarthritis

Correct response: a. Rheumatoid arthritis b. Sickle cell disease c. Systemic lupus erythematosus d. Vasculitis Explanation: Rheumatoid arthritis, Sickle cell disease, Systemic lupus, and vasculitis are all possible causes of osteonecrosis (bone death). Osteoarthritis is not a known cause for this bone pathology.

Which of the following clients presenting to the emergency department would most likely be diagnosed with a pathologic stress fracture? a. A teenager who fell of a ladder and hit the concrete driveway, landing on his hip b. A postmenopausal female who was diagnosed with breast cancer with metastasis to bone c. A competitive volleyball player diving to retrieve a volley and landing on his hip d. A weight lifter who bench-presses 200 kg lost balance and fell to the side, landing on his hip

Correct response: b. A postmenopausal female who was diagnosed with breast cancer with metastasis to bone Explanation: A pathologic stress fracture occurs in bones that already are weakened by disease or tumors. Fractures of this type may occur spontaneously with little or no stress. The underlying disease state can be local, as with infections, cysts, or tumors, or it can be generalized, as in osteoporosis, Paget disease, or disseminated tumors. A fatigue fracture results from repeated excessive wear on a bone. The most common fractures are those resulting from sudden direct impact, such as from a fall or blow, or indirect, such as a massive muscle contraction injury.

Following a knee replacement surgery, a nurse's next door neighbor asks, "I don't think I am healing right. Can you come look at my knee?" Upon assessment, the nurse notices the client is warm to touch and has a fever; the incision is inflamed and not well approximated with foul-smelling drainage around the incision line. At this point, the nurse tells the client she needs to go see her surgeon because the client may have: a. Contaminated the wound with MRSA b. Osteomyelitis c. An abscess in the pocket of the incision d. Potential bone cancer

Correct response: b. Osteomyelitis Explanation: Osteomyelitis after trauma or bone surgery usually is associated with persistent or recurrent fever, increased pain at the operative or trauma site, and poor incisional healing, which often is accompanied by continued wound drainage and wound separation. Prosthetic joint infections often present with joint pain, fever, and cutaneous drainage. There is no indication the client has developed a bone cancer.

Osteonecrosis is a condition in which part of a bone dies because of the interruption of its blood supply. What is the most common cause of osteonecrosis other than fracture? a.Vessel injury b. Prior steroid therapy c. Radiation therapy d. Embolism

Correct response: b. Prior steroid therapy Explanation: Besides fracture, the most common causes of bone necrosis are idiopathic (i.e., those of unknown cause) and prior steroid therapy. Vessel injury, radiation therapy, and embolism can cause osteonecrosis, but not as commonly as the others mentioned.

The nurse assesses the neurovascular status of a patient who had surgery to repair a fractured hip. Which of the following assessment data for the affected leg indicates that the patient has developed a neurological complication? a. Cool skin temperature b. Tingling sensations c. Nonpitting edema d. Ruddy skin color

Correct response: b. Tingling sensations Explanation: Complications of fractures include compartment syndrome when swelling after the injury impairs blood and nerve function, delayed healing, infection, and emboli. Of these conditions, compartment syndrome has the earliest onset. The neurologic assessment includes sensation and the ability to move the toes. Vascular assessment includes capillary refill, edema, and temperature of the distal extremity.

A nursing instructor is teaching students about metabolic bone diseases. She realizes a need for further instruction when one student states which of the following? a. "Osteopenia is a condition common to all metabolic bone diseases." b. "Osteopenia is not a diagnosis." c. "Osteopenia is a condition that is only common in the elderly." d. "Osteopenia can be caused by osteoporosis."

Correct response: c. "Osteopenia is a condition that is only common in the elderly." Explanation: Osteopenia is a condition that is common to all metabolic bone diseases. It is not a diagnosis but a term used to describe an apparent lack of bone seen on an x-ray. It can be seen in any age and can be caused by osteoporosis, osteomalacia, malignancies, and endocrine disorders.

While taking a client history, which of the following findings may lead the nurse to suspect the client is at risk for development of osteonecrosis? a. Previous stress fracture in the hips b. Bacterial infection in the knee following total knee replacement c. Synovial inflammation with painful swelling and warm to touch d. Bone marrow ischemia due to radiation therapy for cancer

Correct response: d. Bone marrow ischemia due to radiation therapy for cancer Explanation: Osteonecrosis refers to necrosis or death of bone and marrow in the absence of infection. All forms of bone necrosis result from ischemia; one of the most common causes is associated with administration of corticosteroids. The site of the lesion is related to ischemia of the vessels involved, rather than a bone fracture or joint area inflammation.

The nurse is assessing a client who sustained a fractured radius. A cast was applied to the extremity approximately 1 hour ago, and the client is now complaining of increased pain and numbness to the finger tips. The client is most likely experiencing: a. Compartment syndrome b. Complex regional pain syndrome c. Fracture blisters d. Thromboemboli

Correct response: a. Compartment syndrome Explanation: Compartment syndrome occurs as a result of increased pressure within a limited space (e.g., abdominal and limb compartments) that compromises the circulation and function of the tissues within the space. The hallmark symptom of an acute compartment syndrome is severe pain that is out of proportion to the original injury or physical findings. Nerve compression may cause changes in sensation (e.g., paresthesias such as burning or tingling or loss of sensation), diminished reflexes, and eventually the loss of motor function. Fracture blisters are skin bullae and blisters. The complex regional pain syndrome or reflex sympathetic dystrophy is caused by involvement of nerve fibers.

The nurse is caring for a client who states that he is suddenly having severe pain at a leg fracture site. The nurse notes increased swelling in the limb and difficulty palpating a pulse. The nurse suspects that the client may have which of the following? a. Compartment syndrome b. Fracture blisters c. Reflex sympathetic dystropy d. Hematogenous osteomyelitis

Correct response: a. Compartment syndrome Explanation: The hallmark symptom of acute compartment syndrome is severe pain out of proportion to the original injury. One of the most important causes of compartment syndrome is bleeding and edema caused by fractures and bone surgery. Edema or swelling may make it difficult to palpate a pulse. Reflex sympathetic dystrophy, while characterized by pain out of proportion to the injury, does not exhibit decreased pulses. Fracture blisters are areas of epidermal necrosis with separation of epidermis from the underlying dermis by edema fluid. They are a warning sign of compartment syndrome. Hematogenous osteomyelitis originates with infectious organisms that reach the bone through the blood stream.

A 56 year-old male is obese and has poorly-controlled type 2 diabetes mellitus. The home care nurse who changes the dressing on his chronic foot ulcer three times weekly has noted that the client's bone is now visible in the wound bed. The client has a fever and has not complained of any notable increase in pain to his foot. Which of the following statements best captures what is likely occurring? a. The client is possibly experiencing direct penetration osteomyelitis in which microorganisms have entered through his foot wound. b. Infectious microorganisms in his blood supply have proliferated in the distal portions of his skeletal system. c. Vascular insufficiency has contributed to infection in both soft tissue and now his bone. d. His immunocompromised status associated with diabetes has allowed skin flora to penetrate his foot bone via the surface wound.

Correct response: c. Vascular insufficiency has contributed to infection in both soft tissue and now his bone. Explanation: Diabetes is strongly associated with vascular insufficiency; this process is more likely than infection from the bloodstream, and his situation is not indicative of direct penetration osteomyelitis. Decreased immune status is not directly responsible for his problem.

Which of the following clients would be considered high risk for falling and fracturing a hip? a. A 54-year-old male with obesity and short stature b. A 36-year-old female whose diet consists of excessive sugar intake c. A 77-year-old male with hearing impairment and corrective eye lenses d. An 81-year-old female taking medication for chronic osteoporosis

Correct response: d. An 81-year-old female taking medication for chronic osteoporosis Explanation: Risk factors for hip fracture include excessive consumption of alcohol and caffeine (rather than sugar), physical inactivity, low body weight, tall stature, use of certain psychotropic drugs, residence in an institution, visual impairment (rather than hearing), and dementia. Osteoporosis weakens the bone and is an important contributing factor. Most hip fractures result from falls.

What is metastatic bone disease most closely associated with? a. Cervical cancer and ovarian cancer b. Acute myelogenous leukemia (AML) and malignant melanoma c. Non-Hodgkin lymphoma and bladder cancer d. Breast cancer and prostate cancer

Correct response: d. Breast cancer and prostate cancer Explanation: Although any cancer can ultimately involve the skeleton, tumors that frequently spread to the skeletal system are those of the breast, lung, prostate, kidney, and thyroid.

Which events in a client's history increase risk of developing osteoarthritis? Select all that apply. a. fractured right radius at age 6 b. torn meniscus in left knee at age 19 c. obesity following pregnancy at age 24 d. hip dislocation at age 35 chicken pox at age 14

orrect response: b. torn meniscus in left knee at age 19 c. obesity following pregnancy at age 24 d. hip dislocation at age 35 Explanation: Knee injuries in young to middle adulthood increase the risk of osteoarthritis, as do hip injuries in middle age. Obesity increases stress on weight bearing joints and increases risk of osteoarthritis. Fractures in young children, and chicken pox are not considered risks for osteoarthritis.

The nurse is caring for a client who sustained a femur fracture three days before. The nurse notes that the client, who was previously oriented, now doesn't know where he is. The nurse suspects which of the following conditions? a. Fat embolism syndrome (FES) b. Reflex sympathetic dystrophy c. Compartment syndrome d. Osteomyelitis

rrect response: a. Fat embolism syndrome (FES) Explanation: The FES refers to multiple life-threatening manifestations from the presence of fat droplets in the small blood vessels of the lung, kidney, brain, and other organs after a long bone (femur) or pelvic fracture. Initial symptoms of FES begin to develop within a few hours to 3 to 4 days after injury. The first symptoms include subtle changes in behavior and signs of disorientation. Reflex sympathetic dystrophy represents soft tissue complications of musculoskeletal injuries. Compartment syndrome is a condition of increased pressure within a limited space. Osteomyelitis represents an acute or chronic infection of the bone.