UWorld - Musculoskeletal

A registered nurse is precepting a new graduate nurse on the orthopedic unit. Which action by the graduate nurse requires the registered nurse to intervene? 1. Elevating a client's residual limb on a pillow 1 day after above-the-knee amputation 2. Placing an abductor pillow between a client's legs after total hip replacement 3. Positioning a client with Buck traction supine with the foot of the bed raised 4. Using pillows to raise a client's extremity following cast placement

1 To prevent hip flexion contractures in clients with above-the-knee amputation, the residual limb should not be elevated, especially after 24 hours. Instead, edema should be managed using a figure eight compression bandage. The bandage should be worn at all times until the residual limb is healed, and care should be taken not to wrap it too tightly. Hip flexion contractures can also be avoided by placing the client in prone position with hip in extension for 30 minutes 3 or 4 times a day. (Option 2) Following total hip replacement, hip dislocation is prevented by using an abductor pillow to maintain the hip in a straight and neutral position. The nurse should also teach the client not to bend at the hip more than 90 degrees or cross the legs or ankles. (Option 3) Buck traction immobilizes hip and femur fractures. A boot or traction tape is applied to the affected extremity and a prescribed weight pulls the limb into traction. The client is typically placed in supine position with the foot of the bed raised to maintain countertraction. (Option 4) After a new cast is placed, the nurse should elevate the client's limb above the heart for the first 48 hours to increase venous return and decrease edema in the affected extremity. However, the extremity should not be elevated if compartment syndrome develops. Educational objective: Care of the client with above-the-knee amputation includes placement in prone position for 30 minutes 3 or 4 times a day and using a figure eight compression bandage to decrease edema. The client's residual limb should not be elevated as this will promote flexion contractures.

The nurse provides discharge teaching to a client who had total hip replacement 4 days ago. Which client statement indicates that additional teaching is necessary? 1. "I will concentrate on leaning forward as I carefully sit down in a chair." 2. "I will do my leg raises and quadriceps and buttock isometric exercises 2-3 times a day." 3. "I will use the sock puller that the therapist gave me when I get dressed." 4. "My child got me a riser for the toilet seat at home. I hope my feet reach the floor!"

1 To prevent hip prosthesis dislocation following hip arthroplasty, a client must not force the hip into >90 degrees of flexion. Clients should use a chair with armrests and a high firm seat and proceed to place the hands on the armrests for support while lowering themselves onto the seat and when rising from it. Bending forward when getting into a chair creates excessive hip flexion (>90 degrees) and must be avoided. (Option 2) The client performs leg exercises 2-3 times a day to help strengthen the muscles surrounding the hip and continues them for several months after discharge. These include isometric quadriceps and gluteal setting, leg raises, and abduction exercises from the supine and standing positions. (Option 3) The client must not twist from the waist, reach across the affected extremity, or bend forward >90 degrees when dressing or putting on slippers, shoes, and socks. The client is instructed to use assistive equipment when getting dressed, such as a reacher/grabber, sock puller, or a long-handled shoehorn. (Option 4) The client should use a toilet riser or a bedside commode chair with arms to prevent excessive hip flexion when getting on and off the toilet seat. Educational objective: To avoid prosthesis dislocation following hip arthroplasty, key discharge teaching points include performing leg exercises to strengthen the muscles around the hip and avoiding excessive hip flexion (>90 degrees) when sitting, dressing, and toileting.

The nurse is assessing a diabetic client for pain following right total knee replacement surgery. The client reports "numbness and tingling" in the bilateral lower extremities. Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe. Which action should the nurse take? 1. Ask if the client wants pain medication for the "numbness and tingling" 2. Ask the client if the "numbness and tingling" were present before surgery 3. Continue assessment by observing the surgical dressing 4. Notify the health care provider (HCP) immediately

2 Numbness and tingling in both lower extremities are classic examples of neuropathic pain. The common causes of bilateral peripheral neuropathy include the following: Diabetic neuropathy - most common; distribution is usually sock-and-glove pattern Autoimmune neuropathy - Guillain-Barré syndrome Toxic neuropathy - alcohol use Establishing that the sensations the client is experiencing were present before surgery indicates whether this is a complication of surgery. Because the sensation is bilateral and the surgery was on the right knee, the "numbness and tingling" are probably baseline diabetic neuropathy. This should be confirmed by gathering more information from the client (Option 2). (Option 1) Diabetic neuropathy is not usually treated with traditional post-surgical medications such as opioids. Medications for diabetic neuropathy are usually given on a fixed, timed schedule and include duloxetine, pregabalin, amitriptyline, and gabapentin. If the client uses an as-needed medication, it is important to ask for more information before administering it. The client should be asked whether the pain is baseline and what medication is taken. (Option 3) The nurse should question any abnormal finding, whether expected or unexpected. Questioning the client further would allow the nurse to gather more information and confirm that the client's "numbness and tingling" do not indicate a more serious situation. (Option 4) It is not necessary to notify the HCP immediately. Bilateral pedal pulses and normal capillary refill indicate sufficient blood flow to the extremities. Educational objective: The nurse should assess for causes of pain and rule out serious complications as part of a pain assessment. Sensations of "numbness and tingling" indicate diabetic neuropathy but should be confirmed as baseline for the client before continuing the assessment.

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear dusky. What are the nurse's appropriate actions? Select all that apply. 1. Apply a heating pad and encourage range-of-motion exercises 2. Assess the temperature and movement of the fingers 3. Elevate the arm on pillows above the level of the heart 4. Notify the health care provider 5. Reassure the client, document findings, and reassess in 1 hour

2, 4 Compartment syndrome, a serious postoperative complication, is caused by decreased blood flow to the tissue distal to the injury. It results from either decreased compartment size (restrictive dressings, splints, or casts) or increased pressure within the compartment (bleeding, inflammation, and edema). Earliest symptoms may include pain or numbness that is unrelieved by medication. Subsequent findings include diminished/absent pulses, pallor, coolness, swelling, decreased movement, and cyanosis. Failure to treat this condition can lead to loss of limb function, paralysis, and tissue necrosis. The nurse should assess neurovascular status and report to the health care provider immediately (Options 2 and 4). Removal of tight bandages/casts and fasciotomy (surgery) are required to relieve the pressure. (Option 1) Heat should not be applied to a client experiencing altered sensation, as it may burn the client. Active range of motion will not resolve compartment syndrome and delays needed care. (Option 3) Elevating the arm on pillows and providing additional analgesia may help reduce symptoms but may also reduce perfusion of the extremity. Instead, the extremity should be positioned at the level of the heart. (Option 5) Documenting findings is important. However, reassurance and reassessment 1 hour later without immediate intervention delays needed care. Educational objective: Compartment syndrome is caused by decreased blood flow to the tissue distal to the injury and can cause ischemic necrosis. Acute compartment syndrome following surgery or casting is potentially limb-threatening and requires emergency evaluation by a health care provider.

The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease process and home management. Which statement by the client indicates comprehension of teaching? 1. "Even with appropriate treatment joint damage and disability are inevitable." 2. "My arthritis can be resolved if I can improve my diet and lose weight." 3. "My methotrexate should be taken even when my joints aren't hurting." 4. "When my joints hurt, I should rest frequently and try not to move them."

3 Rheumatoid arthritis (RA) is a chronic, relapsing autoimmune disorder causing painful inflammation of synovial joints and fibrosis and stiffening of synovial membranes. Contracture of ligaments and joint remodeling may occur, resulting in weakness and deformity. Clients with RA require education on prevention of disease progression, including: Joint protection - Fibrosis from RA can shorten tendons and ligaments when joints are flexed for prolonged periods. Body aligners or immobilizers should be used when resting to keep extremities straight (especially with advanced disease). Medications - RA is often treated using a regimen of disease-modifying antirheumatic drugs (eg, methotrexate), and clients should take their medication as prescribed regardless of symptoms (Option 3). (Option 1) Joint deformity can be prevented with appropriate treatment, including use of disease-modifying antirheumatic drugs and joint protection. (Option 2) Obesity is a risk factor for osteoarthritis, in which mechanical erosion of joint cartilage occurs. However, obesity is unrelated to RA, and clients with RA experience chronic fatigue and pain that may limit oral intake and cause weight loss. The nurse should ensure that clients with RA have access to adequate nutrition. (Option 4) During painful episodes, periods of rest are encouraged; however, clients should frequently perform range of motion exercises to prevent loss of function. Educational objective: Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes pain and joint deformity. Clients with RA should be taught to remain active to prevent contracture, take immunosuppressant medications consistently, use body aligners to prevent joint contracture, and eat a balanced diet. Additional Information Physiological Adaptation NCSBN Client Need