Care of patients with musculoskeletal and connective tissues disorders

The nurse is instructing a patient with rheumatoid arthritis about a prescribed exercise program. Which information should the nurse include? a. Perform exercises every day, 3 to 10 times for every joint. b. Perform exercises even if inflammation is present. c. Perform exercises past the point of pain. d. Perform twice the number of exercises the next day if one day is missed.

ANS: A Exercises are essential to preserve joint function and should be done every day 3 to 10 times per joint. Exercises should be omitted if there is inflammation present and should not be taken past the point of pain, or made up the next day.

A patient in Russell traction with a Pearson attachment for a fracture of the tibia complains of intense pain at the fracture site. The nurse assesses a temperature of 102° F and increased swelling at the fracture site. Which complication do these findings suggest? a. Osteomyelitis b. Fat embolism c. Traction misalignment d. Nonunion of the fracture

ANS: A Osteomyelitis is a bacterial infection of the bone. The causative organism is most often Staphylococcus aureus, which enters the bloodstream from a distant focus of infection, such as a boil or furuncle, or from an open wound, as in an open (compound) fracture. It is usually found in the tibia or fibula, in vertebrae, or at the site of a prosthesis. Osteomyelitis has a sudden onset with severe pain and marked tenderness at the site, high fever with chills, swelling of adjacent soft parts, headache, and malaise. These findings are not consistent with fat embolisms, traction misalignment, or nonunion of the fracture.

Which statement(s) accurately describe the advantage(s) of fiberglass casts? (select all that apply.) a. Lighter weight b. Allowance of weight bearing after 30 minutes c. Cheaper d. Dries more quickly e. Easily pliable f. Smooth surface that is less abrasive to skin

ANS: A, B, D Fiberglass casts are lighter and dry quickly, allowing weight bearing in as little as 30 minutes. Fiberglass casts are very expensive and do not lend themselves to molding to body parts. The surface is very rough and often abrades the skin.

The patient is returning to the unit with a wet long leg cast. To prevent damage to the wet cast, what action(s) should the nurse take? (select all that apply.) a. Determine the cast material. b. Prop the casted limb on a footboard and elevate it until the cast is dry. c. Support the cast with the palms of the hands rather than holding it with the fingers. d. Assess heat generated from the drying cast. e. Explain that the cast has dried when it acquires a grayish color.

ANS: A, C, D Determining the cast material will inform the nurse of how quickly the cast can be expected to dry. The cast should be supported with the palms of the hands rather than holding it with the fingers. The heat of the drying cast should be evaluated to prevent skin irritation. A grayish color indicates that the cast is still wet.

A patient presents to the emergency department immediately after an injury. An x-ray has been ordered for a suspected dislocation. Before confirmation by x-ray, which finding(s) support the potential diagnosis? (select all that apply.) a. History of forceful injury b. Purple-black hematoma over joint c. Severe pain, aggravated by motion d. Muscle spasm e. Abnormal appearance of joint

ANS: A, C, D, E A dislocation will be evidenced by severe pain aggravated by motion, muscle spasm, and an abnormal-appearing joint after the history of a forceful injury. A hematoma, if it forms, will not be evident for a few hours.

The nurse is educating a patient going home with a short arm synthetic cast. Which instructions should the nurse include in the teaching plan? (select all that apply.) a. Cover the cast with a plastic bag when taking a shower. b. Blow warm air into the cast to relieve itching. c. Observe skin at the edge of the cast for irritation or injury. d. Check circulation and sensation in the fingers frequently. e. Move and flex the fingers to stimulate circulation.

ANS: A, C, D, E All options listed are important teaching points for cast care except blowing warm air into the cast. If itching occurs, cool air will be most helpful.

The industrial nurse examines an employee who complains of right shoulder pain on abduction. He points with one finger to the exact location of the pain and mentions that he won a racquetball tournament yesterday. The nurse suspects the employee is suffering from which problem? a. Rotator cuff tear b. Bursitis c. Dislocation d. Subluxation

ANS: B Bursitis occurs after overuse, with pain in the joint on activity with no erythema and little, if any, swelling. Dislocations are very painful and the pain is spread all over the shoulder. The shoulder also looks misshapen in a dislocation. Rotator cuff tear would prevent the patient from abducting his shoulder

Which statement indicates that the patient needs further instruction about application of ice to a sprain? a. "I know this ice will reduce the swelling." b. "I will keep the ice on this knee for the rest of the day." c. "I will use the ice as you have directed for 24 hours." d. "I can elevate my leg and use ice to reduce swelling."

ANS: B Ice should be applied for 20 minutes of each hour for the first 24 hours.

When caring for a patient who has an abductor wedge in place after a total hip replacement, for which finding should the nurse assess? a. Muscle spasms b. Alteration in peripheral circulation c. Compression fracture d. Appropriateness of the size of the wedge

ANS: B Pressure from the abductor wedge can interrupt arterial blood supply and compress the peroneal nerve.

Which vitamin is essential in treating osteoporosis? a. Vitamin A b. Vitamin D c. Vitamin B12 d. Vitamin C

ANS: B Standard treatments for osteoporosis include vitamin D and calcium supplementation, along with weight-bearing exercise. Vitamins A, B12, and C are not included in the standard treatment regimen for osteoporosis.

The patient in a long arm cast (from below the shoulder to the wrist, with a 90-degree elbow flexion) complains of a burning sensation over the elbow. The nurse's initial intervention should be: a. Elevate the casted arm on pillows. b. Check to see if the cast is properly supported. c. Notify the charge nurse of developing pressure ulcer. d. Cut a "window" in the cast.

ANS: B The initial intervention should be to assess for adequate support to the cast, then elevate the limb for 30 minutes. If the pain has not diminished, document the intervention and notify the charge nurse.

The nurse suspects compartment syndrome in a patient with a side arm cast and traction when observing which finding(s)? (select all that apply.) a. Warm, rosy fingers b. Intense pain in hand and fingers c. Edema of fingers d. Weak radial pulse e. Tingling and numbness

ANS: B, C, D, E Compartment syndrome is a restriction of blood flow that occurs in one or more muscle compartments of the extremities. Compartment syndrome is caused by external or internal pressure. The main sign of compartment syndrome is severe, unrelenting pain that is out of proportion to the injury and unrelieved by narcotics. Decreased sensation, numbness and tingling, paleness of the skin, and weakness of the extremity are other signs. Warm, rosy fingers would be assessed as a sign of adequate perfusion.

Soft-tissue injuries require the nurse to assist with or instruct about the importance of which components of care? (select all that apply.) a. Bed rest b. Pain control c. Immobilization d. Activity restrictions e. Prevention of recurrence

ANS: B, C, D, E Pain control, immobilization, activity restrictions, and prevention of recurrence are part of the care to a patient with a soft-tissue injury. Bed rest is not warranted with this type of injury.

The nurse is caring for a patient who just returned from surgical decompression of the carpal tunnel. Which finding requires the nurse's immediate action? a. The patient's fingers swollen and warm. b. The patient complains of generalized pain 5/10. c. The capillary refill time is 8 seconds. d. The patient's fingers are pink and cool bilaterally.

ANS: C A capillary refill of over 5 seconds is an indication of diminished perfusion. Pain and swelling are to be expected, and pink but cool fingers bilaterally do not indicate circulatory compromise.

When the clinic nurse starts to take the "air cast" off the grade 2 sprain, the patient asks why it is being removed since he still has pain. Which explanation is best? a. "Long-term immobilization can interfere with adequate circulation." b. "Long-term immobilization may increase long-term edema." c. "Long-term immobilization can cause permanent disability." d. "This cast will be replaced with a heavier cast."

ANS: C Air casts, braces, or supports are used only until a joint has been strengthened. If a joint is immobilized too long and muscles are not exercised, muscle atrophy—which begins in a matter of days—can cause permanent disability

10. An 80-year-old man falls and suffers a compound fracture of the femur. Which immediate action is most appropriate? a. Position him flat on his back. b. Apply a tourniquet on the leg. c. Carefully splint the leg as it is. d. Carefully straighten the leg.

ANS: C Any fracture, even a compound one, should be immobilized in position to avoid further injury to the soft tissue attached to the bones. Any other initial action may cause further injury.

The nurse is caring for a patient who works as a legal secretary. The patient asks the nurse about ways to avoid developing carpal tunnel syndrome (CTS). Which action should the nurse suggest? a. "Exercise your wrists with repetitive flexion movements nightly." b. "Wrap your wrists with elastic bandages." c. "Acquire a pad to support your wrists while typing." d. "Apply warm compresses to wrists every evening."

ANS: C Elevating the wrist with a firm support eliminates the need to keep the wrists flexed for long periods of time. This wrist support will help prevent CTS. Repetitive motion increases risk for carpal tunnel. Wrapping the wrists or applying warm compresses do not lessen risk of developing carpal tunnel.

The patient with osteoporosis calls the nurse in the doctor's office to report that she should have taken but has forgotten to take her weekly bisphosphonate (alendronate [Fosamax]) that was due 2 days ago. How should the nurse advise the patient? a. "Take the dose now with 8 ounces of water." b. "Take two doses 3 days apart." c. "Skip this week and pick up the schedule next week." d. "Take two tablets now with a snack."

ANS: C If 2 or more days have passed since the regular dose time, this week's dose should be skipped and the weekly schedule should be picked up next week.

Carpal tunnel syndrome (CTS) is caused when the carpal tunnel compresses which location? a. Radial artery b. Brachial artery c. Median nerve d. Ulnar nerve

ANS: C When the median nerve is compressed by the carpal tunnel to the point that numbness, pain, and tingling occur, the result is CTS.

The nurse is performing an assessment on the patient who is in bilateral Buck traction. Which finding indicates the need to reposition the patient? a. The patient's heels are not touching the surface of the mattress. b. The elastic bandages need to be rewrapped. c. The patient's feet are against the footboard. d. The weights are hanging free.

ANS: C When the patient's feet are against the footboard, the traction is ineffective. The heels should be off the surface of the mattress to reduce the threat of pressure ulcer. The weights should be hanging free.

The nurse is performing morning care for a patient who sustained a fractured pelvis and bilateral femur fractures yesterday in a motorcycle collision. The patient complains of shortness of breath. Assessment reveals audible wheezes and oxygen saturation of 76%. What action should the nurse take first? a. Establish a peripheral intravenous (IV) line. b. Inform the charge nurse. c. Explain the patient's change in status to his family. d. Raise patient to high Fowler position.

ANS: D Fat embolism is a rare but serious complication of a fracture of a bone that has an abundance of marrow fat (e.g., the long bones, pelvis, and ribs). In the early postinjury period, patients with multiple fractures resulting from severe trauma are at risk for this complication. Signs and symptoms of fat embolism include a change in mental status, respiratory distress, tachypnea, crackles and wheezes on auscultating the lungs, rapid pulse, fever, and petechiae (a fine red rash over the chest, neck, upper arms, or abdomen). The nurse should stay with the patient; put him in a high Fowler position, use a nonre-breather mask to give high-flow oxygen, and establish a peripheral IV line. The nurse should also summon the provider immediately as there is about an 80% mortality rate from this complication. Raising the patient to high Fowler position is the best initial intervention as it can be done immediately. The nurse should then verify patent IV access, notify the charge nurse and provider, and update the family on the patient's status change.

1. A patient has come to the ambulatory care clinic with a sprain. The nurse correctly differentiates a grade 2 sprain from a grade 3 sprain with the assessment of which finding? a. Pain b. Swelling c. Bleeding into the joint d. Minor loss of function

ANS: D The minor loss of function is the differentiating factor. Pain, swelling, and bleeding into the joint are true of both grade 2 and grade 3 sprains. A grade 3 sprain has loss of function of the joint.

An older adult has fallen and sprained his ankle in a local park. Which action should the responder perform first? a. Elevate the foot. b. Apply ice. c. Administer aspirin. d. Assist the patient with ambulation.

ANS: A Elevation to reduce swelling is the most important initial intervention. Elevation may be done immediately. The responder will have to acquire the ice and pain medication, but should do so as quickly as possible. The responder should not attempt to ambulate the patient at this time.

Which major advantage is specific to external fixation devices? a. Faster healing time b. Allowance for immediate weight bearing c. Greater freedom of movement d. Pain reduction

ANS: C The external device for fracture reduction allows greater freedom of movement, decreasing the problems of immobility. Healing time and pain are the same as with any other fracture reduction method