Prep U's - Chapter 36 - Management of Patients with Musculoskeletal Disorders

Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing bone mass density (BMD)? A. Raloxifene B. Calcitonin C. Vitamin D D. Teriparatide

Answer: B Rationale: Calcitonin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD. Raloxifene reduces the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. Teriparatide has been recently approved by the FDA for the treatment of osteoporosis. Vitamin D increases the absorption of calcium.

What is osteomyelitis characterized by:

Answer: Osteomyelitis is characterized by elevated white blood cell count and erythrocyte sedimentation rate.

A nurse is caring for a client with eczema. Which medication would be prescribed when an allergy is a factor causing the skin disorder? A. Chlorpheniramine B. Bupivacaine C. Dicloxacillin D. Dexamethasone

Answer: A Rationale: Antihistamines such as chlorpheniramine are frequently prescribed when an allergy is a factor in causing a skin disorder. Antihistamines relieve itching and shorten the duration of allergic reaction. Corticosteroids such as dexamethasone are used to relieve inflammatory or allergic symptoms. Antibiotics such as dicloxacillin are used to treat infectious disorders. Local anesthetics such as bupivacaine are used to relieve minor skin pain and itching.

Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes? A. Thoracic B. Lower lumbar C. Cervical D. Upper lumbar

Answer: B Rationale: The lower lumbar disks, L4 to L5 and L5 to S1, are subject to the greatest mechanical stress and greatest degenerative changes.

When an infection is bloodborne, the manifestations include which symptom? A. Hypothermia B. Bradycardia C. Hyperactivity D. Chills

Answer: D Rationale: Manifestations of bloodborne infection include chills, high fever, rapid pulse, and generalized malaise.

The nurse is educating the patient with low back pain about the proper way to lift objects. What muscle should the nurse encourage the patient to maximize? A. Rectus abdominis. B. Latissimus dorsi. C. Gastrocnemius. D. Quadriceps.

Answer: D Rationale: The nurse instructs the patient in the safe and correct way to lift objects using the strong quadriceps muscles of the thighs, with minimal use of weak back muscles (Fig. 42-3).

Which term refers to a disease of a nerve root? A. Involucrum B. Radiculopathy C. Contracture D. Sequestrum

Answer: B Rationale: When the client reports radiating pain down the leg, the client is describing radiculopathy. Involucrum refers to new bone growth around the sequestrum. Sequestrum refers to dead bone in an abscess cavity. Contracture refers to abnormal shortening of muscle or fibrosis of joint structures.

The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response? A. Decrease in parathyroid hormone. B. Increase of vitamin D. C. Increase in calcitonin. D. Decrease in estrogen.

Answer: D Rationale: Age related processes that contribute to loss of bone mass and osteoporosis are decreases in estrogen, calcitonin, and vitamin D and an increase in parathyroid hormone.

A patient had hand surgery to correct a Dupuytren's contracture. What nursing intervention is a priority postoperatively? A. Changing the dressing. B. Applying a cock-up splint and immobilization. C. Having the patient exercise the fingers to avoid future contractures. D. Performing hourly neurovascular assessments for the first 24 hours.

Answer: D Rationale: Hourly neurovascular assessment of the exposed fingers for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion.

Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing BMD? A. Vitamin D B. Raloxifene (Evista) C. Teriparatide (Forteo) D. Calcitonin (Miacalcin)

Answer: D Rationale: Calcitonin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD. Raloxifene reduces the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. Teriparatide has been recently approved by the FDA for the treatment of osteoporosis.

A group of students are reviewing information about osteoporosis in preparation for a class discussion. The students demonstrate a need for additional review when they state which of the following as a risk factor? A. Prolonged corticosteroid use. B. Hypothyroidism. C. Excess caffeine intake. D. Prolonged immobility.

Answer: B Rationale: Factors associated with an increased risk for osteoporosis include: family history of osteoporosis, chronic low calcium intake, excessive intake of caffeine, tobacco use, Cushing's syndrome, prolonged use of high doses of corticosteroids, prolonged periods of immobility, hyperthyroidism, hyperparathyroidism, eating disorders, malabsorption syndromes, breast cancer (especially if treated with chemotherapy that suppresses estrogen, excluding Tamoxifen, which may reduce the risk of fractures), renal or liver failure, alcoholism, lactose intolerance, and dietary deficiency of vitamin D and calcium.

A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening? A. Dislocated jaw. B. Trigeminal neuralgia. C. Temporomandibular disorder. D. Loose teeth.

Answer: C Rationale: The disorder can be confused with trigeminal neuralgia and migraine headaches. The client experiences clicking of the jaw when moving the joint, or the jaw can lock, which interferes with opening the mouth. Loose teeth will not cause a clicking of the jaw. The client does not have a dislocated jaw.

During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse? A. "After age 40, height may show a gradual decrease as a result of spinal compression" B. "There may be some slight discrepancy between the measuring tools used." C. "The posture begins to stoop after middle age." D. "After menopause, the body's bone density declines, resulting in a gradual loss of height."

Answer: D Rationale: The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.

The nurse is preparing a client for a surgical procedure that will allow visualization of the extent of joint damage of the knee for a client with rheumatoid arthritis and also obtain a sample of synovial fluid. What procedure will the nurse prepare the client for? A. Needle aspiration B. Open reduction C. Arthroscopy D. Arthroplasty

Answer: C Rationale: Arthroscopic examination may be carried out to visualize the extent of joint damage as well as to obtain a sample of synovial fluid. An open reduction would be used for the treatment of a fracture. Needle aspiration will not allow visualization of the joint damage but will allow obtaining the sample of synovial fluid. Arthroplasty is the restructure of the joint surface after diagnosis is made.

A family member is caring for an older adult client with osteomalacia in the home. When the home health nurse comes to evaluate the client, what should be a focus point of the visit? A. Ensuring that the client is eating enough. B. Making sure the client has adequate financial resources. C. Observing for safety hazards that could be a fall risk. D. Making sure the client is receiving a daily bath.

Answer: C Rationale: Clients with osteomalacia exhibit a waddling type of gait, putting them at risk for falls and fractures. Safety would be the priority in this circumstance such as scatter rugs, loose boards, and stairs. Older adult clients do not require a daily bath, and it may dry the skin. Nutrition is a necessity to question but the priority would be safety. Whether the client has adequate financial resources would be referred to social service.

Health education for a woman over age 50 includes providing information about the importance of adequate amounts of calcium and vitamin D to prevent osteoporosis. Select the daily dosage of calcium and vitamin D that the nurse should recommend. A. 1,800 mg; 1,600 IU B. 1,600 mg; 1,400 IU C. 1,200 mg; 1,000 IU D. 1,400 mg; 1,200 IU

Answer: C Rationale: The daily recommended dosage is 1,200 mg of calcium and 1,000 IU of vitamin D.

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure? A. Administering large doses of oral antibiotics as ordered. B. Withholding all oral intake. C. Administering large doses of I.V. antibiotics as ordered. D. Instructing the client to ambulate twice daily.

Answer: C Rationale: Treatment of acute osteomyelitis includes large doses of I.V. antibiotics (after blood cultures identify the infecting organism). Surgical drainage may be indicated, and the affected bone is immobilized. The client usually requires I.V. fluids to maintain hydration, but oral intake isn't necessarily prohibited.

A client comes to the emergency department complaining of pain in the right leg. When obtaining the history, the nurse learns that the client has a history of obesity and hypertension. Based on this information the nurse anticipates the client having which musculoskeletal disorder? A. Paget's disease. B. Scoliosis. C. Degenerative joint disease. D. Muscular dystrophy.

Answer: C Rationale: Obesity predisposes the client to degenerative joint disease. Obesity isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease.

A client has low back pain and the healthcare provider needs to rule out the presence of a tumor. Which diagnostic procedure would the nurse anticipate being ordered for the client? A. Computed tomography B. Electromyogram C. Magnetic resonance imaging D. Bone scan

Answer: D Rationale: A bone scan is the preferred diagnostic procedure to disclose tumors in a patient with low back pain. A computerized tomography will identify soft tissue lesions and vertebral disc problems. Magnetic resonance imaging permits visualization of the nature and location of spinal pathology. An electromyogram is used to evaluate nerve root disorders.

On a visit to the family health care provider, a client is diagnosed with a bunion on the lateral side of the great toe at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session? A. "Bunions are congenital and can't be prevented." B. "Bunions may result from wearing shoes that are too big, causing friction when the shoes slip back and forth." C. "Bunions are caused by a metabolic condition called gout." D. "Some bunions are congenital; others are caused by wearing shoes that are too short or narrow."

Answer: D Rationale: Bunions may be congenital or may be acquired by wearing shoes that are too short or narrow, which increases pressure on the bursa at the metatarsophalangeal joint. Acquired bunions can be prevented. Wearing shoes that are too big may cause other types of foot trauma but not bunions. Gout doesn't cause bunions. Although a client with gout may have pain in the big toe, such pain doesn't result from a bunion.

A nurse is teaching a client about preventing osteoporosis. Which teaching point is correct? A. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement. B. To prevent fractures, the client should avoid strenuous exercise. C. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. D. The recommended daily allowance of calcium may be found in a wide variety of foods.

Answer: D Rationale: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary.

A nurse is performing discharge teaching for an elderly client with osteoporosis. Which instruction about a calcium supplement should the nurse include? A. Take the supplement with meals or with orange juice. B. Remain in an upright position 30 minutes after taking the supplement. C. Take the supplement on an empty stomach with a full glass of water. D. Take weekly on the same day and at the same time.

Answer: A Rationale: Calcium supplements should be taken with meals or with a beverage high in vitamin C for increased absorption. Calcium supplements are taken daily, not weekly. There are no special instructions about staying upright when taking calcium supplements.

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate promoting healing? A. Surgical debridement. B. Wound irrigation. C. Wound packing. D. Vitamin supplements.

Answer: A Rationale: In chronic osteomyelitis, surgical debridement is used when the wound fails to respond to antibiotic therapy. Wound packing, vitamin supplements, and wound irrigation are not the standard of care when treating chronic osteomyelitis.

The community health nurse is assessing the risk factors for osteoporosis in a female client at a health fair. For each assessment finding, specify if the finding is a risk factor for osteoporosis or is not a risk factor for osteoporosis. Assessment findings: A. takes fluticasone inhaler for asthma. B. large frame C. Nonsmoker D. postmenopausal status E. 66 years of age F. alcohol intake of 3 drinks/week. G. walks 2 miles, 3 days/week. H. Asian heritage

Answer: A. Risk factor B. Not a risk factor C. Not a risk factor D. Risk factor E. Risk factor F. Not a risk factor G. Not a risk factor H. Risk factor Rationale: After the identification of a client's risk factors for osteoporosis, the nurse can develop a plan of care to reduce or prevent osteoporosis. Risk factors for osteoporosis include older age (for women, the risk increases after age 50), Asian heritage, being a postmenopausal woman, and long-term corticosteroid use (such as fluticasone for the treatment of asthma). A small frame, not a large frame, increases the risk for osteoporosis. Being a nonsmoker does not increase the risk for osteoporosis. An alcohol intake of 3 or more drinks/day is a risk factor for osteoporosis; an intake of 3 alcoholic beverages/week does not increase the risk. A sedentary lifestyle also increases the risk for osteoporosis; however, walking 2 miles, 3 days/week is not considered sedentary.

A client with osteoporosis is prescribed calcitonin 100 units subcutaneously. The medication is available 200 units per ml. How many milliliters will the nurse administer to the client?

Answer: 0.5 mL Rationale: 100 units x 1 ml/200 units = 0.5 ml.

A healthcare provider asks a nurse to test a client for Tinel's sign to diagnose carpal tunnel syndrome. What should the nurse do to perform this assessment? A. Have the client hold the palm of the hand up while the nurse percusses over the median nerve. B. Have the client stretch the fingers around a ball and squeeze with force. C. Have the client pronate the hand while the nurse palpates the radial nerve. D. Have the client make a fist and open the hand against resistance.

Answer: A Rationale: If tingling, numbness, or pain is felt when the median nerve is percussed, then Tinel's sign is considered positive. To test for Tinel's sign have the client hold the palm of the hand up while the nurse percusses over the median nerve. The client making a fist and pushing will test strength resistance. The client stretching fingers around a ball will not test for Tinel's sign. Having the client pronate the hand and palpating the radial nerve is not Tinel's sign used for carpal tunnel syndrome diagnosis.

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing? A. Surgical debridement B. Vitamin supplements C. Wound irrigation D. Wound packing

Answer: A Rationale: In chronic osteomyelitis, surgical debridement is used when the wound fails to respond to antibiotic therapy. Wound packing, vitamin supplements, and wound irrigation are not the standard of care when treating chronic osteomyelitis.

Morton neuroma is exhibited by which clinical manifestation? A. Swelling of the third (lateral) branch of the median plantar nerve. B. High arm and a fixed equinus deformity. C. Diminishment of the longitudinal arch of the foot. D. Inflammation of the foot-supporting fascia.

Answer: A Rationale: Morton neuroma is swelling of the third branch of the median plantar nerve. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Flatfoot is a common disorder in which the longitudinal arch of the foot is diminished. Plantar fasciitis is an inflammation of the foot-supporting fascia.

Which group is at the greatest risk for osteoporosis? A. European American women B. Asian American women C. Men D. African American women

Answer: A Rationale: Small-framed, nonobese European American women are at greatest risk for osteoporosis. Asian American women of slight build are at risk for low peak bone mineral density. African American women, who have a greater bone mass than European American women and Asian American Women, are less susceptible to osteoporosis. Men have a greater peak bone mass and do not experience sudden estrogen reduction.

Which are true about Lyme disease? Select all that apply. A. Early-stage symptoms may include a red macule or papule at the site of the tick bite, a characteristic bullseye rash with round rings around the center, headache, neck stiffness, pain, fever, chills, malaise, nausea, vomiting, and sore throat. B. If untreated, the disease moves through three stages. C. Cardiac and neurological symptoms occur mid-stage, followed by arthritis and joint problems. D. Nephrotic syndromes occur in the later stages.

Answer: A, B, C Rationale: If untreated, the disease moves through three stages. Early stage symptoms may include a red macule or papule at the site of the tick bite, a characteristic bullseye rash with round rings around the center, headache, neck stiffness, pain, fever, chills, malaise, nausea, vomiting, and sore throat. Cardiac and neurologic symptoms occur mid-stage, followed by arthritis and joint problems. There is no kidney involvement with Lyme disease.

A client was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. What would not be a part of teaching plan for this condition? A. encouraging the client to eat a healthy diet. B. applications of ice. C. regular exercise and stress reduction. D. avoiding caffeine and alcohol.

Answer: B Rationale: Application of ice is not part of the treatment regimen. Encouraging the client to eat a healthy diet, avoiding caffeine and alcohol, regular exercise, and stress reduction are part of the teaching plan.

What term refers to a flexion deformity caused by a slowly progressive contracture of the palmar fascia? A. Hammertoe B. Dupuytren contracture C. Hallux valgus D. Callus

Answer: B Rationale: Dupuytren disease results in a slowly progressive contracture of the palmar fascia, called Dupuytren contracture. A callus is a discretely thickened area of skin that has been exposed to persistent pressure or friction. A hammertoe is a flexion deformity of the interphalangeal joint, which may involve several toes. Hallux valgus is a deformity in which the great toe deviates laterally.

The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action? A. Decrease the intake of vitamins A and D. B. Walk or perform weight-bearing exercises. C. Reduce stress. D. Increase fiber in the diet.

Answer: B Rationale: Risk-lowering strategies for osteoporosis include walking or exercising outdoors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, quitting smoking, and consuming alcohol and caffeine in moderation.

The nurse is collaborating with the health care provider on a plan of care for a 54-year-old male client with osteomyelitis of the left femur secondary to uncontrolled type 1 diabetes. Which prescriptions for care should the nurse anticipate for this client? A. Place the left foot in a dependent position. B. Perform neurovascular checks of lower extremities every 8 hours. C. Administer IV antibiotic based on culture and sensitivity report. D. Encourage ambulation with weight-bearing on the left leg. E. Administer ibuprofen 400 mg orally three times daily, as needed for pain. F. Make referral to dietitian to discuss nutrition for healing and blood glucose control. G. Provide education on self-blood glucose monitoring and insulin administration.

Answer: B, C, E, F, G Rationale: Osteomyelitis is a bone infection that produces pain, inflammation, swelling, and impaired mobility and requires prompt treatment to treat the infection and prevent loss of limb. The nurse should perform neurovascular checks of the affected leg every 8 hours to detect the development of nerve or vascular impairment. Osteomyelitis is treated with IV antibiotics determined by the identified pathogen on culture and sensitivity testing. Because there is reduced penetration of antibiotics in the bone tissue, IV antibiotic therapy may be needed for 6 to 12 weeks, followed by oral antibiotics. The pain of osteomyelitis can be controlled with oral analgesics, such as ibuprofen. The client should consume a healthy diet to promote bone healing and control blood glucose levels. Because uncontrolled blood glucose levels increase the risk for osteomyelitis and impair bone healing, the nurse should educate the client about self-blood glucose monitoring and insulin administration. The client's affected left leg should be elevated to reduce swelling and pain. The affected leg should not be placed in the dependent position. Because the bone is weakened by the infectious process, the client should avoid placing stress on the bone through weight-bearing activity.

A client diagnosed with carpal tunnel syndrome (CTS) asks the nurse about numbness in the fingers and pain in the wrist. What is the best response by the nurse? A. "CTS is a neuropathy that is characterized by bursitis and tendinitis." B. "CTS is a neuropathy that is characterized by flexion contracture of the fourth and fifth fingers." C. "CTS is a neuropathy that is characterized by compression of the median nerve at the wrist." D. "CTS is a neuropathy that is characterized by pannus formation in the shoulder."

Answer: C Rationale: Carpal tunnel syndrome is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema, or a soft tissue mass.

A client presents to the emergency department with fever, chills, restlessness, and limited movement of a fractured jaw. What complication should the nurse interpret as the findings? A. Fat embolism. B. Avascular necrosis. C. Compartment syndrome. D. Osteomyelitis.

Answer: D Rationale: Clinical manifestations of osteomyelitis include signs and symptoms of sepsis and localized infection. A client with avascular necrosis does not have fever and chills. Clients with fat emboli will have a rash and breathing complications. A client with compartment syndrome will have numbness, not a fever.

The health care team is caring for a client with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What treatment should the nurse anticipate? A. Supplemental potassium and pancreatic enzymes. B. Colony-stimulating factors and calcitonin. C. Exogenous parathyroid hormone and multivitamins. D. Supplemental calcium and increased doses of vitamin D.

Answer: D Rationale: If osteomalacia is caused by malabsorption, increased doses of vitamin D, along with supplemental calcium, are usually prescribed. PTH, CSF, potassium, and pancreatic enzymes are not indicated.

Which of the following is the most important nursing diagnosis for an elderly patient diagnosed with osteoporosis? A. Deficient knowledge about osteoporosis and the treatment regimen. B. Risk for constipation related to immobility. C. Acute pain related to fracture and muscle spasm. D. Risk for injury related to fractures due to osteoporosis.

Answer: D Rationale: The most important concern for an elderly patient with osteoporosis is prevention of falls and fractures. Pain and constipation can be managed, and knowledge can be reinforced, but fractures can cause significant morbidity and mortality.