Pathophysiology Quiz 6 Musculoskeletal

what are some risk factors for fractures

(1) Advanced age (2) Women (3) Osteoporosis

Most common location of dislocation

(1) Ball and sockets like shoulder are most common

i) Compartment syndromev

(1) Compartments of limb have increased pressure compromising nerves and circulation (1) Result---pressure on nerve endings, blood flow reduced (a) ischemia occurs (i) Increased pain (ii) Change in color (iii) Paresthesia

a) Diagnosis of RA i) Any four of the following criteria must be present - in addition, a provider may order x-ray, draw blood work for and ESR (points toward systemic inflammation and is not specific to RA) and serum rheumatoid factor (not present in all).

(1) Morning stiffness for > 1 hour (2) Arthritis of three or more joints for > 6 weeks (3) Arthritis of hand joints (4) Symmetric arthritis for > 6 weeks (5) Rheumatoid nodules (6) Serum rheumatoid factor positive (7) Radiographic changes typical of RA

What are the two types of fractures

(1) Trauma - fall or impact (2) Pathologic - bone cancer, osteoporosis

5 P's of Compartment Syndrome

(a) Pain - unrelieved by opioids (b) Pulses - distal are absent (c) Paresthesia - distally (d) Pallor - pale on affected limb (e) Paralysis/loss of function

S&S of Dislocation

(i) Pain (ii) Deformity (iii) Swelling (iv) Limited ROM

(a) Treatment of Dislocation

(i) Reduction 1. Manual, surgical, or spontaneous (ii) Splint or sling form multiple weeks

Osteomyelitis

1) bone infection that can linger for a long time

Gout Syndrome

1) gouty arthritis - Increased serum uric acid - crystals precipitate in the joint - inflammation

Stages of Healing (6)

1. Fractures Hematoma 2. Granulation tissue 3. Callus formation 4. Ossification 5. Consolidation 6. Remodeling

15. Which of the following food items are considered an important dietary source of vitamin D? Select all that apply. A) Fish B) Cottage cheese C) Irradiated milk D) Mozzarella cheese sticks E) Apples

Ans: A, C Feedback: Intestinal absorption occurs mainly in the jejunum and includes vitamin D2 and vitamin D3. The most important dietary sources of vitamin D are fish, liver, and irradiated milk. Because vitamin D is fat soluble, its absorption is mediated by bile salts and occurs by means of the lymphatic vessels.

A client presents to the orthopedic clinic for evaluation since the primary care provider thinks the client may have rheumatoid arthritis (RA). Which statement by the client correlates with the diagnosis of RA? Select all that apply. "I'm having a hard time opening doors since it hurts so bad." "Look, I didn't button all my shirt buttons...it just hurts too much and look at the swelling in my hands." "Look how my hand is deformed. My doctor calls it 'hyperextension.'" "Just look at my face. It looks like I have varicose veins on my cheeks." "Every time I get something out of the freezer, my hands turn reddish purple in color."

Ans: A, B, C Feedback: Rheumatoid arthritis (RA) joint involvement usually is symmetric and polyarticular. Pain with turning door knobs, opening jars, and buttoning shirts is commonly reported due to swelling of the wrists and small joints of the hand. Hyperextension of the PIP joint and partial flexion of the distal interphalangeal (DIP) joint is called a swan neck deformity. As the RA inflammatory process progresses, synovial cells and subsynovial tissues undergo reactive hyperplasia. With osteoarthritis (OA), joint changes result from the inflammation caused when the cartilage attempts to repair itself, creating osteophytes or spurs. Raynaud phenomenon (a vascular disorder characterized by reversible vasospasm of the arteries supplying the fingers) and telangiectasia (dilated skin capillaries) are characteristic of scleroderma.

1. Disorders that affect cortical bone typically result in: A) Fractures of long bones B) Impaired collagen synthesis C) Infection D) Vertebral fractures

Ans: A Feedback: Disorders in which cortical bone is defective or reduced in mass lead to fractures of the long bones, whereas those of cancellous bone lead preferentially to vertebral fractures. Neither process directly causes impaired collagen synthesis or infection.

When comparing a child's clinical manifestations with that of oligoarthritis versus systemic onset, the health care provider diagnoses this in your 4-year-old child with oligoarthritis based on which of the following clinical findings? Right knee is warm and painful when putting it through normal range of motion. Faint, red macular rash noted over entire body. Rash is diffuse with severe itching. Daily has an intermittent elevated temperature.

Ans: A Feedback: Oligoarthritis, which is the most common type of JIA, predominantly affects joints of the lower extremities, usually the knees or ankle. Involvement of upper extremity large joints and the hip is rarely a presenting sign. Often a single joint is affected at onset. Children with this form of JIA are usually younger (1 to 5 years at onset) and are often rheumatoid factor (RF) positive. The symptoms of systemic JIA include a daily intermittent high fever, which usually is accompanied by a characteristic faint, erythematous, macular rash. The rash is not pruritic.

A feature of rheumatoid arthritis that differentiates it from other forms of inflammatory arthritis is the development of: Pannus tissue Tophus deposits Subluxations Autoantibodies

Ans: A Feedback: Pannus is a feature of rheumatoid arthritis that differentiates it from other forms of inflammatory arthritis. Pannus, destructive vascular granulation tissue, extends from the synovium to involve the unprotected bone at the junction between cartilage and subchondral bone. Systemic lupus erythematosus (SLE) is characterized by the formation of autoantibodies and immune complexes. RA and SLE are characterized by subluxation of the carpometacarpal joint and other joints. With acute gouty arthritis, there are recurrent attacks of severe articular and periarticular inflammation, resulting in tophus formation (accumulation of crystalline deposits) in articular surfaces, bones, soft tissue, and cartilage.

An elderly female complains about waking up one morning with pain/stiffness in her neck/shoulders. Lab work reveals an elevated erythrocyte sedimentation rate (ESR). The physician gives the client a 3-day trial of prednisone, which significantly improves the pain. The health care provider correlates this information and diagnoses which of the following disorders? Polymyalgia rheumatica Psoriatic arthritis Reiter syndrome Ankylosing spondylitis

Ans: A Feedback: Polymyalgia rheumatica is a common syndrome of older clients, rarely occurring before 50 years and usually after 60 years of age. Reiter syndrome, psoriatic arthritis, and ankylosing spondylitis may occur at younger ages.

A client presents to the pain clinic for a steroid injection into the spine due to increasing pain around the joints. The health care provider tells the client, "You have inflammation where your tendons/ligaments insert into the bone. This injection should help." The nurse assisting with the procedure recognizes this to be characteristic of: Sacroiliitis Calcinosis Excessive bone turnover Autoimmune etiology

Ans: A Feedback: Sacroiliitis is a pathologic hallmark of the spondyloarthropathies. Calcinosis is associated with scleroderma. The spondyloarthropathies do not involve bone turnover, and an autoimmune etiology has not been demonstrated.

While explaining the physiology behind systemic sclerosis (scleroderma), the instructor states, "One of the hallmarks of scleroderma is: Activation of fibroblasts, resulting in fibrosis The development of thin fragile skin Development of a collagen deficiency Avascular necrosis of the femoral head

Ans: A Feedback: Systemic sclerosis, sometimes called scleroderma, is an autoimmune disease of connective tissue characterized by excessive collagen deposition in the skin (with fibrotic thickening) and internal organs, such as the lungs, gastrointestinal tract, heart, and kidneys. Almost all persons with scleroderma develop polyarthritis and Raynaud phenomenon. Musculoskeletal manifestations of systemic lupus erythematosus (SLE), rather than systemic sclerosis, include rupture of the intrapatellar and Achilles tendons and avascular necrosis, frequently of the femoral head. RA granulomatous lesions have a central core of fibrinoid necrosis that is made up of a mixture of fibrin and other proteins such as degraded collagen.

When explaining to the client diagnosed with gout how the xanthine oxidase inhibitors work to help treat gout, the health care provider would include which of the following data? Allopurinol: Blocks the production of uric acid by the body Increases elimination of uric acid by the kidneys Prevents flare-up during the first few months of starting medication Can be given intravenously to rapidly decrease serum uric acid levels

Ans: A Feedback: Xanthine oxidase inhibitors block the synthesis of uric acid. In this classification, the most commonly prescribed to lower urate levels is allopurinol. The uricosuric agents prevent the tubular reabsorption of urate and increase its excretion in the urine. Uricase agents convert insoluble uric acid to a soluble product than can be excreted easily. Pegloticase is an infusible uricase agent that works rapidly to reduce serum uric acid.

15. Following a lengthy series of diagnostic tests, a client's chronic hip pain has been attributed to advanced osteonecrosis. What treatment is this client most likely to require? A) Joint replacement surgery B) Intravenous antibiotics C) Injections of corticosteroids into the synovial space D) Transfusion of packed red blood cells

Ans: A Feedback: Advanced osteonecrosis often necessitates joint replacement surgery, since necrotic bone cannot be rehabilitated. Osteonecrosis is noninfectious in etiology, so antibiotics are not normally necessary. Steroid injections will not restore the affected bone, and blood transfusions do not address the cause of consequences of the problem.

6. A client has fractured his sternum when his chest hit the steering wheel during an accident. Which of the following statements most accurately describes the physiologic function of bone marrow? A) Hematopoiesis takes place in red bone marrow. B) Yellow bone marrow predominates in infants. C) By adulthood, all red bone marrow has been replaced by yellow bone marrow. D) Yellow bone marrow is hematopoietically active in infants, but not in adults.

Ans: A Feedback: Blood cell production takes place exclusively in red bone marrow, which predominates in infants and decreases (but not disappears) with age. Yellow bone marrow is composed primarily of adipose tissue and is not hematopoietically active. As the need for RBC production decreases during postnatal life, red marrow is gradually replaced with yellow bone marrow in most of the bones. In adults, red marrow persists in the vertebrae, ribs, sternum, and ilea.

9. The client has a fractured tibia. After the cast is applied, he is at high risk for compartment syndrome caused by: A) Inflammation B) Joint immobility C) Muscle atrophy D) Extremity elevation

Ans: A Feedback: One of the most important causes of compartment syndrome is bleeding and edema caused by fractures and bone surgery. Compartment syndrome can result from a decrease in compartment size caused by constrictive dressings and casts, increased content volume caused by inflammation, swelling, bleeding, and venous obstruction, or a combination of the two factors. Muscle atrophy decreases volume of contents; casting (rather than immobility caused by the cast) can compress the compartment. Extremity elevation enhances venous return and decreases edema.

20. A couple has just learned that their newborn infant has been diagnosed with osteogenesis imperfecta, and they have responded by seeking out as much information as possible about their child's diagnosis. What should the clinician teach the couple about their child's health problem? A) "This is something that your child may have inherited from one or both of you." B) "This might have been caused by something you were exposed to during the early part of your pregnancy." C) "You'll have to be vigilant of your child's safety for the next few years, but the disease often resolves spontaneously." D) "With aggressive treatment, most children with osteogenesis imperfecta are cured within several months."

Ans: A Feedback: Osteogenesis imperfecta can be inherited as an autosomal recessive or dominant trait; environmental factors are not thought to cause the disease. It is not self-limiting, and there is no known cure.

18. Which of the following lab results may be associated with metastatic bone disease? Select all that apply. A) Elevated alkaline phosphatase B) Decreased creatinine levels C) High serum calcium levels D) Lower serum phosphate levels

Ans: A, C Feedback: 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. Serum levels of alkaline phosphatase and calcium often are elevated in persons with metastatic bone disease. Creatinine levels are not affected by this diagnosis.

10. In third-world countries, many young children with severe vitamin C deficiency will exhibit: A) Impaired formation of the organic matrix B) Calcification of new bone growth C) Growth plate separation D) Widening of the cortex

Ans: A Feedback: Scurvy (i.e., vitamin C deficiency) impairs the formation of the organic matrix of bone, causing slowing of growth at the epiphyseal plate and cessation of diaphyseal growth. In rickets (i.e., vitamin D deficiency), calcification of the newly developed bone is impaired. Epiphyseal separation can occur in children as the result of trauma; blood vessels that nourish the epiphysis rupture, causing cessation of growth and a shortened extremity. Bone growth in diameter occurs as concentric rings containing osteocytes are added to the bone surface cortex, unrelated to vitamin deficiency.

16. Which of the following joints is classified as a synarthrosis? A) The joint between two vertebrae B) The joint between the femur and the pelvis C) The joint between the humerus and the radius and ulna D) An interphalangeal joint of the hand (knuckle)

Ans: A Feedback: Synarthroses are joints that lack a joint cavity and move a little or not at all, such as the vertebral bodies joined by intervertebral disks. The hip joint, elbow, and knuckles are all moveable synovial joints.

2. A college baseball player has seen his season cut short by a rotator cuff injury. Rotator cuff injuries are frequent because of: A) The inherent instability of the shoulder B) The absence of ligaments at the glenohumeral joint C) The vulnerability of the shoulder menisci D) The large mass of the humeral head

Ans: A Feedback: The complexity and flexibility of the shoulder also mean that it is one of the more unstable joints. This makes it extremely vulnerable to injuries, including sprains, dislocations, and degenerative processes such as rotator cuff disorders. The glenohumeral joint contains ligaments, although menisci do not exist in the shoulder. The anatomy of the humerus does not account for the weakness of the joint.

11. The distinguishing characteristic of chronic osteomyelitis is the presence of: A) Sequestrum bone B) Abscess formation C) Severe bone pain D) External drainage

Ans: A Feedback: The hallmark feature of chronic osteomyelitis is the presence of sequestrum, or dead bone that has separated from the surrounding living bone. Chronic osteomyelitis may be the result of delayed or inadequate treatment of acute hematogenous osteomyelitis or osteomyelitis caused by direct contamination of bone. Acute osteomyelitis is usually caused by bacteria. Bone abscesses and fissure formation to the skin surface, with external exudate drainage, are characteristic of severe acute or chronic osteomyelitis.

23. A client with a history of osteoarthritis in his hip, which he refers to as "bad hip," is also complaining of knee pain. The physiological principle behind this would include the fact that: A) All joints of an extremity are innervated by the same peripheral nerves as they travel down the limb. B) If the hip is dislocated, then the knee is not staying in the correct alignment. C) There is more than likely a tear in the synovial membrane, which is impacting the amount of plasma diffusing between the vessels and the joint. D) Synovial tissue has received an injury that is referring pain to the knee.

Ans: A Feedback: The nerve supply to joints is provided by the same nerve trunks that supply the muscles that move the joints. These nerve trunks also supply the skin over the joints. As a rule, all the joints of an extremity are innervated by the same peripheral nerves as they travel down an extremity. The blood supply to a joint arises from blood vessels that enter the subchondral bone at or near the attachment of the joint capsule and form an arterial circle around the joint. The synovial membrane has a rich blood supply, and constituents of plasma diffuse rapidly between these vessels and the joint cavity. Because many of the capillaries are near the surface of the synovium, blood may escape into the synovial fluid after relatively minor injuries. Healing and repair of the synovial membrane usually are rapid and complete. This is important because synovial tissue is injured in many surgical procedures that involve the joint.

6. Following a fracture, the nurse is educating the client and his family about bone healing. The nurse begins by stating: A) "In order to initiate the cellular events essential to bone healing, within a day or so, your body will develop a blood clot at the fracture site." B) "The first thing that will happen is your body will form a soft tissue callus around the fracture site." C) "Your body will first absorb any excess bone fragments that occurred as a result of the break." D) "Just like on your hands after hard work, your body will begin the healing process by forming a callus at the fracture site."

Ans: A Feedback: There are essentially four stages involved in bone healing: hematoma formation, fibrocartilaginous callus development, ossification, and remodeling. Hematoma formation is thought to be necessary for the initiation of the cellular events essential to bone healing. As the result of hematoma formation, clotting factors remain in the injured area to initiate the formation of a fibrin meshwork, which serves as a framework for the growth of fibroblasts and new capillary buds.

21. Which of the following assessment findings on an infant lead the nurse to suspect developmental dysplasia of the hip (DDH), formerly known as congenital hip dislocation? Select all that apply. A) Gluteal fold asymmetry B) Shortening of the thigh, so the knee on affected side is higher C) Joint capsule tightness to the point that there is no normal range of motion D) Delayed crawling on the knees

Ans: A, B Feedback: In infants, signs of possible DDH include asymmetry of the hip or gluteal folds, shortening of the thigh so that one knee (on the affected side) is higher than the other knee, and limited abduction of the affected hip. Instability of the hip may produce a delay in walking. In less severe cases, the hip joint may be unstable, with excessive laxity of the joint capsule.

17. While comparing and contrasting joints, the instructor mentions that the primary role of fibrocartilage includes: Select all that apply. A) Absorption of physical shock B) Provision of flexibility C) Facilitation of long bone growth D) Tissue hydration E) Rigidity

Ans: A, B Feedback: The fibrocartilaginous intervertebral disks between the vertebrae consist of binding connective tissue that holds the vertebrae together. These joints provide strength and shock absorption as well as considerable flexibility. Fibrocartilage is less flexible than other types of cartilage, and hyaline cartilage, not fibrocartilage, contributes to bone growth. Fibrocartilage does not contribute to tissue hydration.

A clinic nurse plans care for a newly diagnosed osteoarthritis client. Which of the following items should this client be provided with educational materials? Select all that apply. Splints to protect and rest the involved joint Use of heat and cold when appropriate for muscle spasms and pain How to use a cane or walker if hip/knees joints are involved High dose of daily glucosamine and chondroitin Narcotics to help control nighttime pain

Ans: A, B, C Feedback: Physical measures are aimed at improving the supporting structures of the joint and strengthening opposing muscle groups involved in cushioning weight-bearing forces. This includes a balance of rest and exercise, use of splints to protect and rest the joint, use of heat and cold to relieve pain and muscle spasm, and adjusting the activities of daily living. The involved joint should not be further abused, and steps should be taken to protect and rest it. These include weight reduction (when weight-bearing surfaces are involved) and the use of a cane or walker if the hips and knees are involved. A recent multicenter trial funded by the National Institutes of Health found that glucosamine and chondroitin (alone or in combination) were no better than placebo in reducing pain in the total group of persons with knee pain. Narcotics are usually not the pain medication of choice for OA.

13. While discussing the role of parathyroid glands in bone formation, the instructor will mention which of the following statements? To maintain adequate serum calcium levels, parathyroid hormone: Select all that apply. A) Activates vitamin D to increase intestinal absorption of calcium B) Reduces serum phosphate levels C) Facilitates release of calcium from the bone D) Stimulates the kidneys to hold on to more sodium E) Reduces tubular reabsorption of phosphates

Ans: A, B, C Feedback: Parathyroid hormone (PTH) maintains serum calcium levels by initiation of calcium release from bone, by conservation of calcium by the kidney, by enhanced intestinal absorption of calcium through activation of vitamin D, and by reduction of serum phosphate levels. Calcium is immediately released from the canaliculi and bone cells; a more prolonged release of calcium and phosphate is mediated by increased osteoclast activity.

1. A child in gymnastics class has fallen off the balance beam and hurt her ankle. X-rays are negative for fracture, so the health care provider has diagnosed a severe sprain. Which of the following treatment measures should be taught to the family and child? Select all that apply. A) Immobilization for several weeks B) Elevate the ankle on pillows C) Apply ice packs to the ankle D) Perform active and passive range-of-motion exercises daily

Ans: A, B, C Feedback: The treatment of sprains involves rest, ice, compression, and elevation (RICE). For an injured extremity such as the ankle, elevation of the injured body part followed by local application of cold may be sufficient. Compression, accomplished through the use of adhesive wraps, helps to reduce swelling and provide support. In a sprain, the affected joint is immobilized for several weeks.

A health care provider suspects a female client (who has had vague complaints over the past several months) may be developing systemic lupus erythematosus (SLE). Which clinical manifestations would correlate with this diagnosis? Select all that apply. Arthralgia Tendon rupture Facial hair growth Uncontrolled hypertension related to pyelonephritis Chest pain that increases with each deep breath

Ans: A, B, E Feedback: Arthralgias and arthritis are among the most commonly occurring early symptoms of SLE. Pulmonary involvement is manifested primarily by pleural effusions and/or pleuritis. Pleural effusions are typically small, bilateral, and exudative. Up to 50% of persons with SLE develop pleuritis (chest pain that increases with each deep breath), which is manifested by pleuritic chest pain. Later manifestations include rupture of the Achilles tendons, hair loss, and forms of glomerulonephritis (rather than pyelonephritis).

Which of the following clients are at risk for developing osteomalacia? Select all that apply. An elderly female who "can't stand to drink milk" and refuses calcium supplements since she has a history of kidney stones A person who lives in a colder region of the northwest who doesn't get out much during the winter months for fear of falling A middle-aged adult with acute renal insufficiency caused by decreased cardiac output prior to having a coronary bypass graft surgery A young 30-year-old African American diagnosed with hypertension who is noncompliant related to taking medication and prescribed diet restrictions A female client whose father had a genetic predisposition to primary hyperparathyroidism resulting in increased calcium resorption from the bone

Ans: A, B, E Feedback: In contrast to osteoporosis (which causes a loss of total bone mass), osteomalacia causes defective mineralization but not the loss of bone matrix. The incidence of osteomalacia is high among the elderly because of diets deficient in calcium and vitamin D. Melanin is extremely efficient in absorbing UVB radiation; thus, decreased skin pigmentation markedly reduces vitamin D synthesis. There also is a greater incidence of osteomalacia in the colder regions of the world, particularly during the winter months when UVB radiation is inadequate to allow skin synthesis of vitamin D. Acute renal insufficiency and uncontrolled hypertension do not relate to defective bone mineralization.

A client presented to the emergency department after getting "hit in the head with a baseball" while watching his grandson play. An x-ray of the head reveals poor quality of bone. The ED physician suspects the client has Paget disease. Which of the following signs/symptoms helps confirm this diagnosis? Select all that apply. "I've had a lot of headaches lately." "Every now and then, I get a ringing in my ears." "Do you see my knuckles...they have big growths on them." "My thumb joint has been cracking every time I rotate it." "I have gotten dizzy and had to sit down while shopping."

Ans: A, B, E Feedback: Skeletal expansion and distortion may be obvious if the disease affects the skull, jaw, clavicle, or long bones of the leg. Involvement of the skull causes headaches, intermittent tinnitus (ringing in the ears), vertigo (dizziness), and eventual hearing loss. The abnormal knuckles and thumb joint are related to arthritis.

7. Which of the following would be considered physiologic characteristics of immature or woven bone? It: Select all that apply. A) Has low tensile strength B) Serves as temporary scaffolding for support C) Serves as weight-bearing pillar D) Is only found in mature adults E) Is found in parts of a healing fracture

Ans: A, B, E Feedback: Immature or woven bone, consisting of trabeculae, looks like poorly organized bone. It is deposited more rapidly than lamellar bone, has low tensile strength, and serves as temporary scaffolding for support. It is found in the developing fetus, in areas surrounding tumors and infections, and as part of a healing fracture. Laminar or mature bone is composed largely of cylinder-shaped units of calcified matrix, called osteons, that are oriented parallel to the long axis of the bone. Functionally, osteons can be thought of as tiny weight-bearing pillars.

19. While explaining the role of synovial fluid, the instructor rewards which student for identifying an accurate response? Select all that apply. A) Supplies nutrient B) Forces water out of the cartilage matrix C) Supplies O2 to chondrocytes D) Brings cells to phagocytize debris in joints E) Lubricates the joint

Ans: A, C, D, E Feedback: The synovium secretes a slippery fluid with the consistency of egg white called synovial fluid. In addition to supplying nutrients and oxygen to the chondrocytes in the articular cartilage, this fluid serves as a lubricant for the joint. Moreover, macrophages in the synovial fluid act to phagocytize debris in the joint space. Matrix components function as a mechanical spring. When pressure is applied, water is forced out of the cartilage matrix into the synovial fluid. When the pressure is released, water is attracted back into the collagen matrix. These water movements, which are brought about by the use of a joint, are essential for the delivery of nutrients and the exchange of carbon dioxide, oxygen, and other molecules between the synovial fluid and articular cartilage.

A 55-year-old male client has reported joint pain in his feet. Which of the following blood work results should prompt further testing to rule out primary gout? Increased C-reactive protein (CRP) Increased serum uric acid Increased polymorphonuclear leukocytes Increased serum cortisol

Ans: B Feedback: Although hyperuricemia is not diagnostic of gout, it is suggestive and should prompt further assessment. Increases in CRP, polymorphonuclear leukocytes, and cortisol levels are not as closely associated with the body's response to gout.

For many clients, the first indication that they have osteoporosis is: Bone pain that is not alleviated by rest A bone fracture Craving high-calcium foods Decrease in range of motion in the hip and knee joints

Ans: B Feedback: Osteoporosis is usually a silent disorder. Often, the first manifestations of the disorder are those that accompany a skeletal fracture—a vertebral compression fracture or fracture of the hip, pelvis, humerus, or other bones. The onset of the disease is not typically marked by pain or decreased range of motion. Clients with osteoporosis are not noted to crave foods that are high in calcium.

Which of the following signs and symptoms should prompt a 29-year-old woman's primary care provider to assess for systemic lupus erythematosus (SLE)? Chronic nausea and vomiting that is unresponsive to antiemetics Joint pain and increased creatinine and blood urea nitrogen A history of thromboembolic events and varicose veins Dysmenorrhea and recent spontaneous abortion

Ans: B Feedback: Renal involvement occurs in approximately one half to two thirds of persons with SLE, and arthralgia is a common early symptom of the disease. Although the manifestations of SLE are diffuse, these do not typically include alterations in hemostasis, gastrointestinal symptoms, dysmenorrhea, or miscarriage.

An elderly resident of an assisted-living facility has had his mobility and independence significantly impaired by the progression of his rheumatoid arthritis (RA). What is the primary pathophysiologic process that has contributed to this client's decline in health? A mismatch between bone resorption and remodeling Immunologically mediated joint inflammation Excessive collagen production and deposition Cytokine release following mechanical joint injury

Ans: B Feedback: The pathogenesis of RA can be viewed as an aberrant immune response that leads to synovial inflammation and destruction of the joint architecture. Paget disease is caused by abnormal bone resorption and remodeling, whereas collagen deposition underlies scleroderma. Osteoarthritis is believed to be initiated by mechanical injury and subsequent cytokine release.

4. 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

Ans: B Feedback: 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.

13. A client is experiencing severe pain in his back to the point of being immobile and running a temperature. The client also has swelling in his lower back (vertebrae). Following biopsy, the results show spinal tuberculosis. The nurse will anticipate explaining which priority intervention to this client? A) Drain the abscess in the lower back B) Administer the four-drug antimicrobial medications C) Locate a chiropractor for pain control D) Log-roll the client while he is on bedrest

Ans: B Feedback: Because there are no specific radiographic findings in tubercular osteomyelitis, the diagnosis is usually made by tissue biopsy or culture findings. In spinal tuberculosis, a computed tomography (CT)-guided biopsy is often used. The mainstay of treatment for tubercular osteomyelitis remains the appropriate three- or four-drug antimicrobial therapy based on current guidelines. Conservative treatment is usually as effective as surgery, especially for earlier and milder cases.

25. Magnetic resonance imaging of a client's knee has revealed the presence of bursitis. The nurse should anticipate performing which intervention for bursitis? A) Applying Buck's traction with 10-pound weights B) Placing an ice pack on the knee to decrease swelling C) Administering an antihistamine like Benadryl to minimize inflammation D) Obtaining a surgical permit to repair the bursae

Ans: B Feedback: Bursae contain synovial fluid, and they exist to prevent friction on a tendon. They are necessary in areas where pressure is exerted because of close approximation of joint structures. Bursae may become injured or inflamed, causing discomfort, swelling, and limitation in movement of the involved area. Buck's traction, Benadryl, and surgery are not the standard treatment for bursitis.

1. A gymnastics student lands awkwardly and hurts her ankle. After MRI scan, it was revealed that she has a torn cartilage. The health care worker states it may take up to 3 to 4 months for this injury to heal. The basic physiologic reason behind the prolonged recovery is due to the fact that cartilage is/has primarily: A) The main secretor of an extracellular matrix B) Avascular C) Low tensile strength D) Lacking minerals

Ans: B Feedback: Cartilage is avascular tissue, a fact that stands in contrast to bone tissue. Both bone and cartilage contain cells that secrete an extracellular matrix, which forms the structure of the tissue. Cartilage is more flexible than bone, but it also exhibits considerable tensile strength. Cartilage repair is a particularly slow process and may in fact not occur in some cases. In contrast to cartilage, the extracellular matrix of bone is mineralized, producing a hard tissue capable of providing support for the body and protection for its vital structures.

12. An increase in the level of RANKL would result in: A) Fusing of the epiphysis and metaphysis in long bones B) Changes in the rate of bone remodeling C) Decreased production of PTH D) Increased vitamin D activation

Ans: B Feedback: Correct regulation of the RANKL/RANK/OPG pathway is necessary for normal bone remodeling and a balance between bone resorption and bone formation. The pathway in general, and levels of RANKL in particular, does not directly influence levels of PTH and vitamin D. RANKL has no bearing on the fusing of epiphyses and metaphyses.

10. A child has been hospitalized for the treatment of hematogenous osteomyelitis. The defining characteristic of this type of osteomyelitis is: A) The presence of dead bone tissue B) Introduction of microorganisms from the bloodstream C) Bacterial proliferation in the absence of the classic signs of infection D) Destruction of the vascular network in the endosteum

Ans: B Feedback: Hematogenous osteomyelitis originates with infectious organisms that reach the bone through the bloodstream. Dead bone tissue is indicative of osteonecrosis, not osteomyelitis. Hematogenous osteomyelitis is normally accompanied by the classic signs and symptoms of infection; the destruction of the vascular network in the endosteum is not a hallmark of the hematogenous variant of osteomyelitis.

2. Hyaline cartilage is a firm but flexible type of connective tissue that is essential for: A) Calcium salt storage B) Growth of long bones C) Bone surface perfusion D) Reduced friction on tendons

Ans: B Feedback: Hyaline cartilage is essential for growth before and after birth. As long bones grow in length, the deeper layers of cartilage cells in the growth plate multiply and enlarge, pushing the articular cartilage farther away from the metaphysis and diaphysis. Because cartilage has no blood vessels, this tissue fluid allows diffusion with blood vessels outside the cartilage. Cartilage dies if it becomes calcified. Bursae are located near joints and contain synovial fluid; their purpose is to prevent friction on a tendon.

22. Assessment of a newborn infant reveals the presence of developmental dysplasia of the hip (DDH) that is currently demonstrated by subluxation of the baby's hip joint and a general laxity in the baby's ligaments. What measures should be emphasized in this infant's treatment? A) Corticosteroid therapy B) Close observation C) Open reduction D) Joint reconstruction

Ans: B Feedback: Less severe cases of DDH in which dislocation is not present often resolve spontaneously and do not require surgical correction. If the condition does not resolve, a Pavlik harness is used on newborns (up to 6 months) to maintain the femoral head in the acetabulum. Pharmacologic treatments are not central to the management of DDH.

12. 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

Ans: B Feedback: 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.

14. While discussing hormonal control of bone formation, one should note that which hormone lowers blood calcium levels and decreases bone resorption? A) Vitamin D B) Calcitonin C) Prolactin D) Phosphate

Ans: B Feedback: Whereas parathyroid hormone (PTH) increases blood calcium levels, the hormone calcitonin lowers blood calcium levels by inhibiting the release of calcium from bone into the extracellular fluid and by decreasing bone resorption. Vitamin D functions as a hormone in regulating body calcium; it increases calcium absorption from the intestine and promotes the actions of PTH on bone. PTH and prolactin stimulate vitamin D production by the kidney. Changes in the concentration of phosphate ions may affect serum calcium levels due to their inverse relationship. Phosphate is not a hormone.

25. While explaining to the parents of a child diagnosed with postural scoliosis, the nurse will emphasize which of the following concepts? This form of scoliosis: A) Compresses vertebrae, causing nerve damage in distal limbs B) Can be corrected with bending and active/passive exercises C) Is congenital in nature and responds poorly to treatment measures D) Is often a long, C-shaped curve from the cervical area to sacral region and is very painful

Ans: B Feedback: With postural scoliosis, there is a small curve that corrects with bending. It can be corrected with passive and active exercises. Structural scoliosis does not correct with bending. It is a fixed deformity classified according to the cause: congenital, neuromuscular, and idiopathic. Congenital scoliosis is caused by disturbances in vertebral development during the 6th to 8th week of embryologic development. In neuromuscular scoliosis, there is often a long, C-shaped curve from the cervical to the sacral region. It is seen in children with cerebral palsy, in whom severe deformity may make treatment difficult.

8. A physiology instructor asks the class, "What role do osteoblasts play in the physiology of bone tissue?" The student with the best answer would be: A) Differentiation into mature bone cells B) Synthesis and secretion of the bone matrix C) Maintenance of calcium balance D) Resorption of the bone matrix

Ans: B Feedback: Osteoblasts are bone-building cells that synthesize and secrete the bone matrix. Osteogenic cells differentiate into mature bone cells, whereas osteocytes and osteoclasts maintain calcium balance. The bone matrix is reabsorbed by osteoclasts.

After numerous trips to the physician's office, a client is diagnosed with diffuse scleroderma based on which of the following clinical manifestations? Select all that apply. Protruding eyeball with very red, inflamed eyes and associated photophobia. Difficulty swallowing resulting in weight loss due to malabsorption. Spider veins on the face and chest. Hands turn bluish purple when getting items out of the freezer. Inability to walk long distances with severe leg cramping in calf muscles.

Ans: B, C, D Feedback: Some persons with scleroderma have limited involvement and may develop the CREST syndrome, characterized by a combination of calcinosis (i.e., calcium deposits in the subcutaneous tissue that erupt through the skin), Raynaud phenomenon (a vascular disorder characterized by reversible vasospasm of the arteries supplying the fingers), esophageal dysmotility, sclerodactyly (localized scleroderma of the fingers), and telangiectasia (dilated skin capillaries). Protruding eyeball is related to hyperthyroidism, and inability to walk distances without cramping is known as claudication caused by poor circulation.

21. A basketball player fell awkwardly when attempting to claim a rebound, a mishap that resulted in a tear to the anterior cruciate ligament (ACL) of his left knee. The school nurses will anticipate the player to exhibit which of the following clinical manifestations? Select all that apply. A) Immoveable (locked) knee joint B) Intense pain C) Abscess formation D) Edema (swelling) of the knee E) Large hematoma on the anterior knee surface

Ans: B, D Feedback: Ligaments are pliable enough to permit movement at the joints, but they tear rather than stretch when exposed to excess stress. Torn ligaments are extremely painful and accompanied by local swelling. Torn ligaments do not form abscesses or large hematomas.

16. While explaining to a group of nursing students the difference between benign and malignant bone tumors, the instructor will emphasize that a benign tumor: Select all that apply. A) Is associated with constant, deep aching pain that does not go away with rest B) May be asymptomatic and detected incidentally C) Is a painful mass that is detected on a long bone and seems to be increasing in size D) May cause the client to have a pathological fracture

Ans: B, D Feedback: There are three major manifestations of bone tumors: pain, presence of a mass, and impairment of function. Although benign tumors are frequently asymptomatic and are detected as an incidental finding, malignant tumors are associated with constant, deep aching pain that does not go away with rest and is present at night. A mass or hard lump may be the first sign of a bone tumor. A malignant tumor is suspected when a painful mass exists that is enlarging or eroding the cortex of the bone. Benign and malignant tumors may cause the bone to erode to the point where it cannot withstand the strain of ordinary use. A sudden increase in pain followed by trivial trauma that is preceded by a history of mild, dull aching pain is suggestive of a pathologic fracture.

Which of the following measures should a public health nurse recommend to middle-aged women to reduce their chances of developing osteoporosis later in life? Weight control and daily use of low-dose corticosteroids Genetic testing and range-of-motion exercises Calcium supplementation and regular physical activity Increased fluid intake and use of vitamin D supplements

Ans: C Feedback: Although the use of vitamin D supplements may be of preventative value for some clients, the primary prevention measures for osteoporosis include calcium supplementation and regular exercise. Genetic testing and increased fluid intake are not relevant measures, and corticosteroids are a risk factor for osteoporosis.

A female client presents to the orthopedic clinic for evaluation. The primary care provider told her she has a "spur" on her joint. She asks, "Why did this happen? I guess I just didn't exercise enough." The nurse recognizes this to be a later structural change of osteoarthritis (OA), where the client no longer has a "shock absorber," culminating in: Osteonecrosis and loss of synovial fluid Formation of tophi in the synovial space Osteophyte formation and erosion of cartilage Separation of the epiphyseal plate

Ans: C Feedback: As OA progresses, cartilage is lost and osteophytes, or spurs, develop on the surface of the articulating bones. Osteonecrosis does not typically develop, and synovial fluid is not lost. Tophi are associated with gout, not OA, and the epiphyseal plate does not separate in the course of OA.

An adult female client visits with her health care provider about pain in her hand. She describes it as an audible grinding and cracking sound, especially in her thumb. "I had to buy an automatic jar opener...I just can't grasp and open a jar...it just hurts too badly." The health care provider suspects the client has a degenerative form of joint disease that is often evidenced by: Rheumatoid arthritis Systemic lupus erythematosus Osteoarthritis Ankylosing spondylitis

Ans: C Feedback: In osteoarthritis (OA) syndrome, crepitus and grinding may be evident when the osteoarthritic joint is moved. OA joint enlargement results from new bone formation and the joint feels hard, in contrast to the soft, spongy feeling characteristic of the joint in rheumatoid arthritis (RA). The person with ankylosing spondylitis typically reports low back pain, which becomes worse when resting, particularly when lying in bed. Systemic lupus erythematosus (SLE) is characterized by the formation of autoantibodies and immune complexes (type III hypersensitivity). SLE has the capacity to affect many different body systems, including the musculoskeletal system, skin, cardiovascular system, lungs, kidneys, central nervous system (CNS), and red blood cells and platelets.

A young adult male client presents to the orthopedic clinic complaining of "stiffening of the spine." The health care provider orders some diagnostic lab work. Which lab result leads the health care worker to diagnose ankylosing spondylitis? Elevated serum calcium level of 15.1 mg/dL Severe decrease in red blood cells associated with decreased iron levels Presence of HLA-B27 allele marker Elevated serum uric acid level

Ans: C Feedback: The HLA-B27 antigen remains one of the best-known examples of an association between a disease and a hereditary marker; approximately 90% of those with ankylosing spondylitis possess the HLA-B27 antigen. Primary gout is often caused by an inborn error in metabolism and is characterized primarily by hyperuricemia and gout. The person also may have a mild normocytic normochromic anemia but not iron deficiency anemia.

A female athlete has been diagnosed with amenorrhea due to intense training for a spot on the Olympic swimming team. As a health care provider, which of the following should be implemented to prevent premature osteoporosis? Encourage a minimum of 10 hours of sleep/night. Increase dietary intake of protein and iron. Calcium/vitamin D supplements to support BMD. Watch sodium intake and eat a carb-consistent diet with lots of fruits.

Ans: C Feedback: The female athlete triad, a pattern of disordered eating that leads to amenorrhea and eventually premature osteoporosis, is being seen increasingly in female athletes because of an increased prevalence of eating disorders. Poor nutrition, combined with intense exercise training, can lead to decrease in the critical body fat-to-muscle ratio needed for normal menses and estrogen production by the ovary. The lack of estrogen combined with the lack of calcium and vitamin D from dietary deficiencies results in a loss of bone density and increased risk of fractures. Older athletes are at high risk for osteoarthritis, a degenerative joint disorder that is unrelated loss of bone density.

18. In contrast to synarthrosis joints, which synovial joints allow for movement in all directions? A) Knee joints B) Elbow joints C) Shoulder joints D) Vertebrocostal joints

Ans: C Feedback: Although as a group they are classified as freely moveable, synovial joints include planar joints, which allow almost no movement (e.g., vertebrocostal joint), and hinge joints, which allow angular movement in one plane (e.g., interphalangeal, knee, and ankle joints). Only the ball-and-socket joints permit movement in all directions (e.g., shoulder or hip joint).

20. Intercellular collagen fibers provide what function for tendons and ligaments? A) Elastic recoil B) Shape flexibility C) Tensile strength D) Inorganic calcium

Ans: C Feedback: Intercellular fibers found in skeletal tissue are mainly collagenous and elastic. Collagen is an inelastic and insoluble fibrous protein that has great tensile strength. Elastin is the major component of flexible elastic fibers that allows the fibers to stretch and rapidly recoil when tension is released. The intercellular matrix, rather than fiber, contains organic matter (collagen fibers in an amorphous ground substance) and inorganic matter (several forms of calcium).

24. A child with a diagnosis of Legg-Calvé-Perthes disease will exhibit: A) Defective synthesis of type I collagen B) Congenital dislocation of the acetabulofemoral joint C) Necrosis of the proximal femoral head D) Intoeing due to metatarsus adductus

Ans: C Feedback: Legg-Calvé-Perthes disease is an idiopathic osteonecrotic disease of the proximal (capital) femoral epiphysis. DDH involves congenital dislocation of the acetabulofemoral joint, whereas defective synthesis of type I collagen accounts for the pathologic effects of osteogenesis imperfecta. Intoeing is neither a cause nor a consequence of Legg-Calvé-Perthes disease.

24. While lifting weights during football season, a player hears a loud "pop." This is primarily associated with a loss of which function? A) Autonomic nerve fibers B) Supporting bursa sacs C) Reflexive proprioception D) Elastic articular cartilage

Ans: C Feedback: Tendons and ligaments of the joint capsule connect muscles and bones, are sensitive to position and movement, and have reflexive proprioceptor responses to adjust and maintain supporting muscle tension for the joint. The joint capsule synovial membrane is innervated only by autonomic fibers that control blood flow. Bursae, closed sacs of synovial fluid, prevent friction in areas where tendons are deflected over bone, rather than maintaining muscle support. Cartilage is devoid of blood vessels and nerves; elastic-type cartilage is found in areas such as the ear.

22. How are the oxygenation needs of the articulating areas in a synovial joint met? A) Capillaries release oxygenated blood into the synovial cavity at a controlled rate. B) The cartilage of the articulating areas uses anaerobic metabolism exclusively. C) Oxygen is provided to the articulating areas indirectly by synovial fluid. D) The epiphyses of long bones provide oxygen to the articulating areas.

Ans: C Feedback: The articulating areas are nourished indirectly by the synovial fluid that is distributed over the surface of the articular cartilage. Blood is not normally released into the synovial cavity, and the cells of the articulating areas are not capable of anaerobic metabolism. The epiphyses of long bones do not provide oxygen to the articulating areas in a synovial joint.

19. A client with a diagnosis of small cell lung carcinoma has developed bone metastases, a finding that has prompted a series of new interventions. What are the primary goals of the treatment regimen for this client's bone cancer? A) Prevention of brain metastasis and early identification of osteonecrosis B) Promotion of bone remodeling at tumor sites through calcium and vitamin D supplements C) Prevention of pathologic fractures and maximization of function D) Pain management and prevention of osteomyelitis

Ans: C Feedback: The primary goals in treatment of metastatic bone disease are to prevent pathologic fractures and promote survival with maximum functioning, allowing the person to maintain as much mobility and pain control as possible. Osteonecrosis, osteomyelitis, and brain metastasis are not typical sequelae of bone metastasis. Tumor sites do not normally undergo remodeling, and dietary supplements alone would not foster this process.

11. Which of the following statements about bone mass and the elderly is accurate? A) Bone mass is increased with aging due to all the wear and tear of the joints. B) Once skeletal growth has been attained, there is no longer any replacement or repair. C) Bone resorption and formation are no longer perfectly coupled, and bone mass is lost. D) Hormones, like PTH, are much slower to be released as one ages.

Ans: C Feedback: In the adult, the length of one sequence (i.e., bone resorption and formation) is approximately 4 months. Ideally, the replaced bone should equal the absorbed bone. If it does not, there is a net loss of bone. In the elderly, for example, bone resorption and formation no longer are perfectly coupled, and bone mass is lost. Once skeletal growth has attained its adult size, the breakdown and renewal of bone that is responsible for skeletal maintenance is initiated at sites that require replacement or repair. This process is called bone remodeling. As long as the parathyroid glands are healthy, they will remain as important regulators of calcium and phosphate levels in the blood.

8. Which of the following factors may adversely affect bone healing and therefore place the client at risk for long-term problems? Select all that apply. A) Immobilization due to skeletal traction B) Walking with a walker with minimal weight bearing on affected side C) Delayed union at the fracture site within a period considered the normal healing time D) History of uncontrolled diabetes mellitus with associated circulatory problems

Ans: C, D Feedback: Delayed union is the failure of a fracture to unite within the normal period (e.g., 20 weeks for a fracture of the tibia or femur in an adult). Malunion is caused by inadequate reduction or malalignment of the fracture. For healing to occur, the bone needs to be aligned and immobilized to maintain the alignment during bone remodeling. Individual factors that may delay bone healing are the client's age; current medications; debilitating diseases, such as diabetes and rheumatoid arthritis; local stress around the fracture site; circulatory problems and coagulation disorders; and poor nutrition. Weight bearing helps to maintain some area muscle tone while the bone is immobilized, avoiding muscle atrophy and loss of range of motion.

A 77-year-old woman has been admitted to the geriatric medical unit of the hospital for the treatment of pneumonia. The nurse providing care for the client notes the presence of nasal calcitonin, vitamin D, and calcium chloride on the client's medication administration record. The nurse should conclude that this client likely has a history of: Scleroderma Osteoarthritis Rheumatoid arthritis Osteoporosis

Ans: D Feedback: Common pharmacologic treatments for osteoporosis include nasal calcitonin, vitamin D supplements, and calcium supplements. This combination of drugs does not address the etiology or manifestations of scleroderma, osteoarthritis, or rheumatoid arthritis.

2. The condition that contributes to the pathology of all metabolic bone diseases is: A) Impaired vitamin D synthesis B) Osteosarcoma C) Infection D) Osteopenia

Ans: D Feedback: Osteopenia is a condition that is common to all metabolic bone diseases. Metabolic diseases are noninfectious and are not neoplastic. Impaired vitamin D synthesis can cause osteopenia, but this phenomenon is not common to all metabolic bone diseases.

A 26-year-old woman has sought care for increasing pain at the back of her ankle and the bottom of her foot over the past 2 weeks. The client states that she is generally in good health, although she completed a course of antibiotics for a chlamydial infection 6 weeks earlier. This client's recent history suggests the possibility of: Systemic sclerosis Ankylosing spondylitis Osteoarthritis Reactive arthritis

Ans: D Feedback: Reactive arthritis may be triggered by infections such as that caused by Chlamydia trachomatis. The Achilles tendon and plantar fascia are the most common sites of involvement, and this is nearly always accompanied by pain. Osteoarthritis, systemic sclerosis, and ankylosing spondylitis are not suggested by this specific chain of events.

14. 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

Ans: D Feedback: 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.

17. A client presents to a health care clinic reporting sudden onset of deep, localized pain and swelling in her proximal femur. The client is currently undergoing diagnostic workup for suspected lung cancer. The nurse suspects the client may have developed which of the following neoplasms of the skeletal system? A) Exostosis B) Osteochondroma C) Endochondroma D) Osteosarcoma

Ans: D Feedback: Osteosarcoma is an aggressive and highly malignant bone tumor that normally requires surgery and chemotherapy. Exostosis and osteochondroma are synonymous terms for types of benign neoplasms that often require no treatment. Endochondroma is also benign and may self-resolve.

7. A client's clavicular fracture has healed in the weeks following a bicycle accident. Which of the following events takes place in the remodeling stage of bone healing? A) Formation of granulation tissue B) Development of fibrocartilage that resembles the appearance of the original bone C) Deposition of mineral salts into the callus D) Reduction in the size of the callus

Ans: D Feedback: Remodeling involves resorption of the excess bony callus that develops in the marrow space and encircles the external aspect of the fracture site. As the callus matures and transmits weight-bearing forces, the portions that are not stressed are resorbed. As a result, the callus is reduced in size until the shape and outline of the bone have been reestablished. Formation of granulation tissue, the development of fibrocartilage, and the deposition of mineral salts all precede the remodeling stage.

3. 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

Ans: D Feedback: 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.

5. A client presents to the emergency department following an accident where he fell off a chair. He reports hip numbness, increasing pain, and muscle cramping. The triage nurse suspects: A) Dislocated joint B) Osteosarcoma C) Osteomyelitis D) Closed hip fracture

Ans: D Feedback: Shortly after a fracture has occurred, nerve function at the fracture site may be temporarily lost. The area may become numb, and the surrounding muscles may become flaccid. After this brief period, the pain sensation returns and with it muscle spasms and contractions of the surrounding muscles. There are pain, tenderness at the site of bone disruption, swelling, loss of function, deformity of the affected part, and abnormal mobility.

5. A long bone, such as the humerus of the upper arm, has which of the following structural characteristics? A) A perichondrium that overlies most of the bone surface B) A durable outer shell made of cancellous bone C) A diaphysis at each end D) An endosteum composed of osteogenic cells

Ans: D Feedback: The endosteum is the membrane that lines the spaces of spongy bone, the marrow cavities, and the haversian canals of compact bone. It is composed mainly of osteoprogenitor cells that contribute to the growth and remodeling of bone and that are necessary for bone repair. The principle functions of the periosteum and endosteum are the nutrition of bone tissue and continuous supply of new osteoblasts for repair and growth of bone. The perichondrium lines cartilage, not bone, and the outer shell of long bones is compact, or cortical, bone. The diaphysis is the medial section of long bone; an epiphysis is found at each end of the bone.

23. An infant is born with a clubfoot. The nurse should anticipate which of the following treatment measures may be instituted? A) Surgery prior to leaving the hospital B) Administration of muscle-relaxing medications C) Skeletal traction with pins inserted into affected bones D) Serial manipulations and casting

Ans: D Feedback: Treatment of clubfoot is begun as soon as the diagnosis is made. When treatment is initiated during the first few weeks of life, a nonoperative procedure may be effective. Serial manipulations and casting are used gently to correct each component of the deformity. Surgery, muscle-relaxing medications, and skeletal traction are not primary treatment for clubfoots.

4. When describing the covering on bones to the students, the instructor asks, "Why is periosteum an important part of the bone covering?" The student responses should mention which of the following? It: A) Is composed of a single layer of osteoprogenitor cells B) Is the site of red blood cell development C) Supplies yellow bone marrow to assist with adipose cell production D) Contains blood vessels that assist with providing nutrition to bone tissue

Ans: D Feedback: Bones are covered, except at their articular ends, by a periosteum membrane. The periosteum contains blood vessels and acts as an anchorage point for blood vessels as they enter and leave the bone. The endosteum is the membrane that is considerably thinner than the periosteum and is composed of a single layer of flattened osteoprogenitor cells and small amounts of connective tissue. Red bone marrow contains developing red blood cells and is the site of blood cell formation. Yellow bone marrow is composed largely of adipose cells. At birth, nearly all of the marrow is red and hematopoietically active.

9. Which of the following serves as a communicating channel for exchange of nutrients and metabolites between the osteocytes and the blood vessels on the surface of the bone layer? A) Woven bone B) Volkmann canals C) Osteons D) Canaliculi

Ans: D Feedback: Extracellular fluid-filled passageways permeate the calcified matrix and connect with the lacunae of adjacent osteocytes. These passageways are called canaliculi. Because diffusion does not occur through the calcified matrix of bone, the canaliculi serve as communicating channels for the exchange of nutrients and metabolites between the osteocytes and the blood vessels on the surface of the bone layer. Woven bone is deposited more rapidly than lamellar bone, has low tensile strength, and serves as temporary scaffolding for support. Laminar or mature bone is composed largely of cylinder-shaped units of calcified matrix, called osteons, that are oriented parallel to the long axis of the bone. Canals of a second type called perforating, or Volkmann, canals lie at right angles to the long axis of the bone, connecting the vascular and nerve supplies of the periosteum and medullary cavity.

3. When discussing the interior quality of bones, the science instructor mentions that spongy bone has which of the following unique qualities? Select all that apply. A) Rigidity B) Thickness C) A growth plate D) Tensile strength E) Weight-bearing properties

Ans: D, E Feedback: Cancellous (spongy) bone is relatively light and composed of trabeculae of bone that form a lattice-like pattern. Its structure is such that it has considerable tensile strength and weight-bearing properties. Compact (cortical) bone forms the outer shell of a bone and has a densely packed calcified matrix that makes it more rigid than cancellous bone, without excessive thickness. Although the cancellous bone contains osteocytes to maintain the bony matrix, active bone growth occurs at the epiphyseal growth plate.

3. Callus formation

i) within a week, new cartilage is formed composed of calcium phosphorus and osteoblasts linking the bone ends. It then ossifies and links the bone fully, bringing them closer.

5. Consolidation

ii) callus continues to develop decreasing the distance between the bone fragments. When complete, osteoclasts start to reabsorb excess bone.

1. Fractures Hematoma

immediately after fracture, bleeding & edema occur. Within 72 hours.

Sprain

injured joint ligaments

DEXA Scan

measures bone density

1) Rheumatoid Arthritis

a) Autoimmune disorder - type III hypersensitivity (immune complexes that are circulating destroy joint cartilage and surrounding structures), synovial membrane thickens (reduced perfusion and ischemia of cells in joint), unknown etiology. Insidious, chronic, progressive inflammation of joints.

Osteoporosis is...

a) Decreased bone mineral density (BMD) b) Decreased cancellous (spongy) bone strength c) Decreased bone matrix and mineralization d) Bone resorption > bone formation

Osteoarthritis (OA)

a) Degenerative joint disease - cartilage deteriorates

S&S of Osteomyelitis

a) Hematogenous - fever and chills b) Direct entry - afebrile, but with pain and tenderness at site of bone

9) Which of the following represents the correct sequence of bone healing? a) Hematoma cartilage bone b) Hematoma elastin fibrocartilage c) Cartilage spongy bone compact bone d) Hemangioma spongy bone compact bone

a) Hematoma cartilage bone

Two types of OA

a) Idiopathic or primary OA—usually oligoarticular b) Secondary OA—congenital or acquired i) Hx of RA ii) Athletes

Paget Disease

a) Regions of excessive bone turnover. i) New bone is disorganized, mosaic appearance

What is happening to the joint in RA

a) Synovial inflammation and joint architecture destruction i) Vague in the beginning ii) Inflammation iii) Decreased ROM in finger hands, wrist and elbow iv) Deformities in hands and fingers (swan and boutonniere, ulnar drift) v) Rheumatoid nodules are systemic complications that form on the lungs, heart, eyes or spleen.

Tophi

a) accumulation of crystalline deposits

Treatment of Osteoporosis

pharmacologic treatment to maintain instead of replacing. OTC treatment is vitamin D and calcium together.

RICE

rest, ice, compress, elevate

1) Which of the following involves problems with purine metabolism? a) SLE b) Gout c) Rheumatoid arthritis d) Spondyloarthropathy

b) Gout

a) Treatment of Haematogenous

i) Several weeks of IV antibiotics to treat acute (1) If unable to self-administer, must remain in the hospital ii) Because of the sequestrum, chronic osteomyelitis can last for year because ABX cannot reach bone.

1) True or false? a) When osteoblasts work harder than osteoclasts, bones grow.

i) True, osteoblasts build bone while osteoclasts break down tissue. So which is more active or working harder determines what is going on with the bone.

2. Granulation tissue

i) between 48 and 72 hours. phagocytosis occurs. Replaces hematoma with granulation tissue, where osteoblasts cells start to build new bone, new capillaries are formed, and hematoma is replaced

Strain

i) injured muscle or tendon

Hematoma

i) large pooled blood presses on nerve endings (1) Larger than a bruise and take a longer time to heal

Contusion, bruise

i) ruptured blood vessels (1) Common in contact sports

6. Remodeling

i) union is complete (1) OsteoBLAST = BUILDS bone (stimulated by the hormone calcitonin) (2) OsteoCLAST = REABSORBS bone (stimulated by parathyroid hormone) (3) Cast applied for first 6-8 weeks to help bone heal in the correct position (4) Remodeling can take up to a year

Pannus

destructive vascular granulation tissue destructive to adjacent cartilage and bone

Dislocation

displacement of joint articulation structures

4. Ossification

i) 2-3 weeks after break, a permanent callus of woven bone forms ii) Consolidation-callus continues to develop decreasing the distance between the bone fragments. When complete, osteoclasts start to reabsorb excess bone.

a) Acute or chronic Osteomyelitis

i) Acute - <6 weeks ii) Chronic - >6 weeks

a) Treatment of Gou

i) Allopurinol ii) NSAIDs (not Aspirin) iii) 3 liters of water per day to prevent formation of uric acid.

Symptoms of Osteoporosis

i) Besides bone frequent fractures, loss of height or low back pain, there are relatively few symptoms

Common Locations for Paget Disease

i) Common in spine, cranium, pelvis (1) Large cranium (2) Bowlegs (3) Bone pain (4) Fatigue

Complications of OA

i) Creating osteophytes or spurs ii) Hebrideans and bouchons nodes

a) Direct-entry or hematogenous Osteomyelitis

i) Direct-entry - surgery, trauma, iv drug use (1) Staph aureas enters bone, initiates inflammation and purulence, ischemia, poor perfusion (2) In chronic, the entire bone can be infected. Differentiated from acute because of sequestrum and involucrum. ii) Haematogenous osteomyelitis - is an infection caused by bacterial seeding from the blood, involves a single species of microorganism (typically a bacterium), occurs primarily in children, and is most common in the rapidly growing and highly vascular metaphysis of growing bones.

a) Gouty nephropathy

i) Glomeruli cannot process crystals

a) Clinical manifestations of OA

i) Inflammation and swelling, warm to touch, dull achy pain, crepitus, decreased ROM, edema.

Three function of Calcitonin Hormone:

i) Lowers serum calcium levels ii) Inhibits osteoclast activity iii) Stimulates osteoblast activity and uses blood calcium to build bone

two functions of Parathyroid Hormone:

i) Maintains (raises) serum levels of ionized calcium ii) Stimulates osteoclasts to break down a nd release calcium into the blood

a) Risk factors of Paget Disease

i) Mid adulthood ii) Family hx iii) European history

a) Medications for Rheumatoid Arthritis - starting treatment early provides best prognosis for patients. Suppressing immune system or relieving inflammation

i) NSAIDs and COX-2 inhibitors - suppress inflammation ii) Corticosteroids - suppress inflammation iii) Disease-modifying antirheumatic drugs (DMARDs) (suppresses immune system by suppressing type III hypersensitivity) (1) Methotrexate, leflunomide iv) Biologic agents (also used in cancer treatments) (1) Infliximab, abatacept, tocilizumab, tofacitinib v) Prevent deformations from RA and promote function of patients with RA

a) Risk Factors of OA

i) Obesity, advanced age, heredity

Three functions of Vitamin D

i) Regulates calcium and phosphate homeostasis (1) Balances activity between osteoblasts and osteoclasts ii) osteoclast number and activity iii) osteoblast differentiation

Treatments of OA

i) Rest ii) Heat and Cold iii) NSAIDS iv) Non-weight bearing exercise v) Surgical arthroplasty