Ch 36: Management of of Patients with Musculoskeletal Disorders

a) Open nerve release Pg. 1118 Evidence-based treatment of acute carpal tunnel syndrome includes the application of splints to prevent hyperextension and prolonged flexion of the wrist. Should this treatment fail, open nerve release is a common surgical management option. A variety of treatments may be tried by the client, however, they may fail to improve the condition. These treatments include laser therapy, ultrasound therapy, and the injection of substances such as lidocaine. Though these can be used, surgery to release nerves is the best option.

1. A client with carpal tunnel syndrome has had limited improvement with the use of a wrist splint. The nurse knows that which procedure will show the greatest improvement in treatment for this client? a) Open nerve release b) Ultrasound therapy c) Injection of lidocaine d) Laser therapy

a) Teriparatide Pg. 1138 Teriparatide (Forteo) is a subcutaneously administered anabolic agent that is taken once daily. The other drug choices are oral preparations.

13. A provider prescribes a subcutaneous anabolic agent for an older adult client to prevent fractures associated with osteoporosis. What is the most likely prescribed drug? a) Teriparatide b) Alendronic acid c) Calcitonin d) Raloxifene

c) At least 4 weeks Pg. 1142 Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for at least 4 weeks, followed by another 2 weeks (or more) of IV antibiotics or oral antibiotics.

19. A client with diabetes punctured the foot with a sharp object. Within a week, the client developed osteomyelitis of the foot. The client was admitted for IV antibiotic therapy. How long does the nurse anticipate the client will receive IV antibiotics? a) 6 months b) 7 to 10 days c) At least 4 weeks d) 3 months

a) Osteitis deformans Pg. 1141 Osteitis deformans (Paget disease) results in bone that is highly vascularized and structurally weak, predisposing to pathologic fractures. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Osteoporosis is characterized by reduction of total bone mass and a change in bone structure that increases susceptibility to fracture. Osteomyelitis is an infection of bone that comes from the extension of a soft-tissue infection, direct bone contamination, or hematogenous spread.

26. Localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae, is characterized by which bone disorder? a) Osteitis deformans b) Osteoporosis c) Osteomyelitis d) Osteomalacia

d) Long bone bowing Pg. 1141 Some clients with Paget's disease are asymptomatic with only some mild skeletal deformity. Other clients have marked skeletal deformities which may include enlargement of the skull, bowing of the long bones, and kyphosis.

3. Assessment of a client reveals signs and symptoms of Paget's disease. Which of the following would be most likely? a) Upright gait b) Lordosis c) Skull narrowing d) Long bone bowing

b) Calcitonin Pg. 1136 Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased in osteoporosis. Estrogen, which inhibits bone breakdown, decreases with aging. On the other hand, parathyroid hormone (PTH) increases with aging, increasing bone turnover and resorption. The consequence of these changes is net loss of bone mass over time. Corticosteroids place patients as risk for developing osteoporosis.

4. Which of the following inhibits bone resorption and promotes bone formation? a) Corticosteroids b) Calcitonin c) Estrogen d) Parathyroid hormone

d) Decreased height Pg. 1136 Clients with osteoporosis become shorter over time.

5. What clinical manifestation would the nurse expect to find in a client who has had osteoporosis for several years? a) Increased heel pain b) Bone spurs c) Diarrhea d) Decreased height

b) Carpal tunnel syndrome Pg. 1118 Carpal tunnel syndrome is commonly due to repetitive hand activities. A ganglion is a collection of gelatinous material near the tendon sheaths and joints that appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. Dupuytren's contracture is a slowly progressive contracture of the palmar fascia. Impingement syndrome is associated with the shoulder and may progress to a rotator cuff tear.

8. Which common problem of the upper extremity results from entrapment of the median nerve at the wrist? a) Dupuytren's contracture b) Carpal tunnel syndrome c) Ganglion d) Impingement syndrome

a) Decrease in estrogen Pg. 1135 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.

21. 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 estrogen b) Decrease in parathyroid hormone c) Increase in calcitonin d) Increase of vitamin D

c) Plantar fasciitis Pg. 1121 Plantar fasciitis, an inflammation of the foot-supporting fascia, present as an acute onset of heal pain experienced with the first steps in the morning. Hallux valgus (commonly called a bunion) is a deformity in which the great toe deviates laterally. Morton's neuroma is a swelling of the third (lateral) branch of the median plantar nerve. A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm compressible cystic swelling, usually on the dorsum of the wrist.

27. Which of the following presents with an onset of heel pain with the first steps of the morning? a) Morton's neuroma b) Hallux valgus c) Plantar fasciitis d) Ganglion

a) Wear properly fitting shoes Pg. 1123 Hammer toe is a flexion deformity of the PIP joint and may involve several toes and may result from wearing poorly fitting shoes. They will not straighten by binding the toes or doing active range of motion exercises. Surgery is an option but should be discussed with an orthopedic surgeon or podiatrist.

31. The nurse is assisting a client with removing shoes prior to an examination and observes that the client has a flexion deformity of several toes on both feet of the proximal interphalangeal (PIP) joints. What can the nurse encourage the client to do? a) Wear properly fitting shoes b) Do active range of motion on the toes c) Have surgery to fix them d) Bind the toes so that they will straighten

c) Walk or perform weight-bearing exercises outdoors Pg. 1134 Risk-lowering strategies for osteoporosis include walking or exercising outdoors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine in moderation.

11. The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action? a) Decrease the intake of vitamin A and D b) Increase fiber in the diet c) Walk or perform weight-bearing exercises outdoors d) Reduce stress

b) Management of plantar fasciitis includes stretching exercises Pg. 1121 Management also includes wearing shoes with support and cushioning to relieve pain, orthotic devices (e.g., heel cups, arch supports), and the use of nonsteroidal anti-inflammatory drugs. Plantar fasciitis, an inflammation of the foot-supporting fascia, presents as acute-onset heel pain experienced upon taking the first steps in the morning. The pain is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon. Unresolved plantar fasciitis may progress to fascial tears at the heel and eventual development of heel spurs.

12. Which should be included in the teaching plan for a client diagnosed with plantar fasciitis? a) The pain of plantar fasciitis diminishes with warm water soaks b) Management of plantar fasciitis includes stretching exercises c) Complications of plantar fasciitis include neuromuscular damage and decreased ankle range of motion d) Plantar fasciitis presents as acute-onset pain localized to the ball of the foot that occurs when pressure is placed on it and diminishes when pressure is released

b) Common adverse effects Pg. 1115 The most common adverse effects of NSAIDs are related to the GI tract: nausea, vomiting, diarrhea, and constipation. GI bleeding, which in some cases is severe, has been reported with the use of these drugs. Use of NSAIDs does not pose significant dietary or activity restrictions nor is there a loading-dose schedule.

20. A client has experienced increasing pain and progressing inflammation of the hands and feet. The rheumatologist has prescribed NSAID use to treat the condition. What client education is most important for the nurse to address with the use of these medications? a) Dietary restrictions b) Common adverse effects c) Loading-dose schedule d) Activity restrictions

d) Dupuytren contracture Pg. 1119 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.

25. What term refers to a flexion deformity caused by a slowly progressive contracture of the palmar fascia? a) Hallux valgus b) Hammertoe c) Callus d) Dupuytren contracture

d) Walking Pg. 1139 Weight-bearing exercises should be incorporated into the client's lifestyle activities. Walking is a low-impact method of weight-bearing exercise and would be the most universal or most likely form of exercise for the nurse to recommend. Bicycling, and swimming are not weight-bearing exercise and will not increase bone density. Yoga may or may not be weight-bearing exercise depending on the yoga poses being performed; it is not as likely as walking to be recommended by the nurse.

28. A nurse is planning discharge teaching regarding exercise for a client at risk for osteoporosis. Which exercise would the nurse be most likely to suggest? a) Swimming b) Bicycling c) Yoga d) Walking

d) Chills Pg. 1142 Manifestations of bloodborne infection include chills, high fever, rapid pulse, and generalized malaise.

29. When an infection is bloodborne, the manifestations include which symptom? a) Hypothermia b) Hyperactivity c) Bradycardia d) Chills

c) Surgical debridement Pg. 1143 In chronic osteomyelitis, antibiotics are adjunctive therapy to surgical debridement.

30. In chronic osteomyelitis, antibiotics are adjunctive therapy in which situation? a) Vitamin supplements b) Wound packing c) Surgical debridement d) Wound irrigation

c) Alendronate Pg. 1138 Alendronate is a bisphosphonate medication. Raloxifene is a selective estrogen receptor modulator. Teriparatide is an anabolic agent, and denosumab is a monoclonal antibody agent.

17. The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given? a) Raloxifene b) Teriparatide c) Alendronate d) Denosumab

c) "I will avoid prolonged sitting or walking" Pg. 1115-1116 The nurse encourages the patient to alternate lying, sitting, and walking activities frequently, and advises the patient to avoid sitting, standing, or walking for long periods.

10. The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided? a) "Instead of turning around to grasp an object, I will twist at the waist" b) "I will bend at the waist when I am lifting objects from the floor" c) "I will avoid prolonged sitting or walking" d) "I will lie prone with my legs slightly elevated"

a) Bone fracture Pg. 1134 Bone fracture is a major complication of osteoporosis; it results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause — not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance isn't a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

2. A nurse is caring for an elderly female client with osteoporosis. When teaching the client, the nurse should include information about which major complication? a) Bone fracture b) Negative calcium balance c) Dowager's hump d) Loss of estrogen

a) Temporomandibular disorder Pg. 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.

7. 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) Temporomandibular disorder b) Dislocated jaw c) Trigeminal neuralgia d) Loose teeth

a) Immobilize the client's arm Pg. 1145 Signs of a fracture in an extremity include pain, deformity, swelling, discoloration, and loss of function. When a nurse suspects a fracture, the extremity should be immobilized before moving the body part. It isn't appropriate for the nurse to move the client into a sitting position without further assessment. The client shouldn't walk to the nurses' station; the client should wait for help to arrive.

18. A nurse notices a client lying on the floor at the bottom of the stairs. The client is alert and oriented and denies pain other than in the arm, which is swollen and appears deformed. After calling for help, what should the nurse do? a) Immobilize the client's arm b) Help the client walk to the nearest nurses' station c) Place the client in a sitting position d) Raise the client's arm above the heart

b) "After menopause, the body's bone density declines, resulting in a gradual loss of height" Pg. 1136 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.

23. 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) "The posture begins to stoop after middle age" b) "After menopause, the body's bone density declines, resulting in a gradual loss of height" c) "There may be some slight discrepancy between the measuring tools used" d) "After age 40, height may show a gradual decrease as a result of spinal compression"

d) Arthroscopy Pg. 1145 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.

24. 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) Arthroplasty c) Open reduction d) Arthroscopy

d) Chlorpheniramine Pg. 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.

32. 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) Dicloxacillin b) Bupivacaine c) Dexamethasone d) Chlorpheniramine

b) "You will receive IV antibiotics for 3 to 6 weeks" Pg. 1142-1143 Treatment of osteomyelitis requires IV antibiotics for 3 to 6 weeks. Continuous passive range of motion is used for clients with osteoarthritis. Weight-bearing exercises are used with clients who have osteoporosis. Limiting protein and calcium is not part of the plan of care for clients with osteomyelitis.

14. A nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching? a) "You need to perform weight-bearing exercises twice a week" b) "You will receive IV antibiotics for 3 to 6 weeks" c) "You need to limit the amount of protein and calcium in your diet" d) "Use your continuous passive motion machine for 2 hours each day"

d) Perform neuromuscular assessment every hour Pg. 1122 The priority nursing intervention is to perform a neuromuscular assessment every hour. Early detection of neurological and perfusion problems is important to prevent complications from the surgery. The surgical dressing does not need to be examined hourly. Administering pain medication is important, but assessing the foot color and temperature are most important. Vital sign monitoring is important, but not a priority after foot surgery.

15. A nurse is caring for a client following foot surgery. Which nursing intervention is most important for the nurse to include in the nursing care plan? a) Administer pain medication per client request b) Examine the surgical dressing every hour c) Monitor vital signs every 4 hours d) Perform neuromuscular assessment every hour

Risk factors: a) 66 years of age c) Asian heritage d) Postmenopausal status g) Takes fluticasone inhaler for asthma Not risk factors: b) Large frame e) Nonsmoker f) Alcohol intake of 3 drinks/week h) Walks 2 miles, 3 days/week Pg. 1134-1140 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.

22. The community health nurse is assessing the risk factors for osteoporosis in a female client at a health fair. Determine which are risk factors for osteoporosis and not risk factors. a) 66 years of age b) Large frame c) Asian heritage d) Postmenopausal status e) Nonsmoker f) Alcohol intake of 3 drinks/week g) Takes fluticasone inhaler for asthma h) Walks 2 miles, 3 days/week

a) Surgical debridement Pg. 1143 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.

9. 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 packing d) Wound irrigation

a) "CTS is a neuropathy that is characterized by compression of the median nerve at the wrist" Pg. 1118 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.

16. 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 compression of the median nerve at the wrist" b) "CTS is a neuropathy that is characterized by bursitis and tendinitis" c) "CTS is a neuropathy that is characterized by flexion contracture of the fourth and fifth fingers" d) "CTS is a neuropathy that is characterized by pannus formation in the shoulder"

d) Places the load close to the body Pg. 1114 Instructions for the client with low back pain should include that, when lifting, the client should avoid overreaching. The client should also keep the load close to the body, bend the knees, and tighten the abdominal muscles; use a wide base of support; and use a back brace to protect the back. Bending at the hips increases the strain on the back muscles when lifting.

33. The nurse is educating a client with low back pain on proper lifting techniques. The nurse recognizes that the education was effective when the client a) Bends at the hips and tightens the abdominal muscles b) Reaches over the head with the arms fully extended c) Uses a narrow base of support d) Places the load close to the body

c) Has a weight gain of 5 pounds Pg. 1122 Obesity is a risk factor for osteoarthritis. Excess weight is a stressor on the weight-bearing joints. Weight reduction is often a part of the therapeutic regimen.

6. The client with osteoarthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care? a) Reports decreased joint pain b) Shows increased joint flexibility c) Has a weight gain of 5 pounds d) Reports ability to perform ADLs