Ch. 68 Musculoskeletal Problems

1. A patient who has osteomyelitis is to receive vancomycin 500 mg IV every 6 hours. The vancomycin is diluted in 100 mL of normal saline and needs to be administered over 1 hour. The nurse would set the IV pump to deliver how many milliliters per minute?

ANS: 1.67 To administer 100 mL in 60 minutes, the IV pump will need to provide 1.67 mL/min

2. A patient is being discharged after 1 week of IV antibiotic therapy for osteomyelitis in the right leg. Which information would the nurse include in the discharge teaching? a. How to administer prescribed antibiotics at home b. How to apply warm packs to the leg to reduce pain c. The need for daily aerobic exercise to maintain muscle strength d. The need to stop taking the antibiotics when the leg pain decreases

ANS: A Most patients start on IV antibiotics then switch to oral therapy; the patient will be taking antibiotics for several months and should not stop when the pain decreases. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.

18. Which action would the nurse take when caring for a patient who has osteomalacia? a. Remind the patient to avoid any sun exposure. b. Teach about the use of vitamin D supplements. c. Instruct the patient to avoid dairy products in the diet. d. Discuss the use of medications such as bisphosphonates.

ANS: A Osteomalacia is caused by inadequate intake or absorption of vitamin D, so supplements will be needed. Dairy products contain calcium, which is needed. Bisphosphonate administration may be used for osteoporosis but is not beneficial for osteomalacia. Because ultraviolet light is needed for the body to synthesize vitamin D, the patient might be taught that 20 minutes a day of sun exposure is beneficial.

1. Which actions would the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur? (Select all that apply.) a. Monitor serum calcium. b. Teach about the need for strict bed rest. c. Explain the use of sustained-release opioids. d. Support the left leg when repositioning the patient. e. Assist family and patient as they discuss the prognosis.

ANS: A, C, D, E The nurse will monitor for hypercalcemia caused by bone decalcification. Support of the leg helps reduce the risk for pathologic fractures. Although the patient may be reluctant to exercise, activity as tolerated is important to maintain function and avoid complications associated with immobility. Adequate pain medication, including sustained-release and rapid-acting opioids, is needed for the severe pain often associated with bone cancer. The prognosis for metastatic bone cancer is poor, so the patient and family need to be supported as they deal with the reality of the situation.

5. A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action would the nurse include in the plan of care? a. Logroll the patient every 2 hours. b. Assist the patient with ambulation. c. Discuss the need for genetic testing with the patient. d. Teach the patient about the muscle biopsy procedure.

ANS: B Because the goal for the patient with muscular dystrophy is to keep the patient active for as long as possible, assisting the patient to ambulate will be part of the care plan. The patient will not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but are not necessary for a patient who already has a diagnosis. There is no need for genetic testing because the patient already knows the diagnosis.

20. A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient would the nurse assess first? a. Patient who reports foot pain after hammertoe surgery b. Patient who has not voided 8 hours after a laminectomy c. Patient with low back pain and a positive straight-leg-raise test d. Patient with osteomyelitis who has a temperature of 100.5F (38.1C)

ANS: B Difficulty in voiding may indicate damage to the spinal nerves and would be assessed and reported to the surgeon immediately. The information about the other patients is consistent with their diagnoses. The nurse will need to assess them as quickly as possible, but the information about them does not indicate a need for immediate intervention.

7. A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse teaches the patient correct body mechanics, which patient statement indicates the teaching has been effective? a. "I will keep my back straight when I lift above my waist." b. "I will begin doing exercises to strengthen and support my back." c. "I will tell my boss I need a job where I can stay seated at a desk." d. "I can sleep with my hips and knees extended to prevent back strain."

ANS: B Exercises can help strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back than keeping these joints extended. Sitting for prolonged periods can aggravate back pain. Modification in the way the patient lifts boxes is needed, but the patient should not lift above the level of the elbows.

8. Which action would the nurse take when repositioning the patient who has just had a laminectomy and discectomy? a. Instruct the patient to move the legs before turning the rest of the body. b. Place a pillow between the patient's legs and turn the entire body as a unit. c. Have the patient turn by grasping the side rails and pulling the shoulders over. d. Turn the patient's head and shoulders first, followed by the hips, legs, and feet.

ANS: B Have the patient logroll when changing position in bed to keep the spine in correct alignment after laminectomy. Twisting motions created by moving the body in segments will create misalignment of the spine.

1. A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention would the nurse include in the initial plan of care? a. Quadriceps-setting exercises b. Immobilization of the left leg c. Positioning the left leg in flexion d. Assisted weight-bearing ambulation

ANS: B Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fracture. Weight-bearing exercise increases the risk for pathologic fractures and is not recommended until the infection is treated. Muscle contractions with exercises may lead to muscle spasms, causing pain, but will be used after the infection is resolved. Flexion of the affected limb is avoided to prevent contractures.

10. Which assessment finding for a 55-yr-old patient would alert the nurse to the presence of osteoporosis? a. Bowed legs b. Loss of height c. Report of frequent falls d. Aversion to dairy products

ANS: B Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia and osteoarthritis. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis.

19. Which action would the nurse take first when a patient is seen in the outpatient clinic with neck pain? a. Provide information about therapeutic neck exercises. b. Ask about numbness or tingling of the hands and arms. c. Suggest the patient alternate the use of heat and cold to the neck. d. Teach about the use of nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: B The nurse's initial action would be further assessment of related symptoms because cervical nerve root compression will require different treatment than musculoskeletal neck pain. The other actions may also be appropriate, depending on the assessment findings.

16. Which action would the nurse complete before administering alendronate (Fosamax) to a patient with osteoporosis? a. Ask about any leg cramps or hot flashes. b. Assist the patient to sit up at the bedside. c. Be sure that the patient has recently eaten. d. Administer the ordered calcium carbonate.

ANS: B To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates.

3. A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. Which statement by the patient would indicate to the nurse the need for additional teaching related to health maintenance? a. "Itake my oral temperature twice a day." b. "I'm frustrated with this endless treatment!" c. "Ithink my left foot is starting to droop down." d. "I use crutches to avoid bearing weight on the left leg."

ANS: C Footdrop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis.

4. The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which patient statement indicates to the nurse that additional teaching is needed? a. "I will need to participate in physical therapy after surgery." b. "I wish I did not need to have chemotherapy after this surgery." c. "I did not have this bone cancer until my leg broke a week ago." d. "I can use the patient-controlled analgesia (PCA) to manage postoperative pain."

ANS: C Osteogenic sarcoma may be diagnosed following a fracture, but it is not caused by the injury. The other statements indicate patient teaching has been effective.

17. Which action included in the care of a patient after laminectomy can the nurse delegate to experienced assistive personnel (AP)? a. Check ability to plantar and dorsiflex the foot. b. Determine the patient's readiness to ambulate. c. Log roll the patient from side to side every 2 hours. d. Ask about pain management with the patient-controlled analgesia (PCA).

ANS: C Repositioning a patient is included in the education and scope of practice of AP, and experienced AP will be familiar with how to maintain alignment in the postoperative patient. Evaluation of the effectiveness of pain medications, assessment of neurologic function, and evaluation of a patient's readiness to ambulate after surgery require higher level nursing education and scope of practice.

6. Which information would the nurse include in the teaching plan for a patient who has acute low back pain and muscle spasms? a. Keep both feet flat on the floor when prolonged standing is required. b. Twist gently from side to side to maintain range of motion in the spine. c. Keep the head elevated slightly and flex the knees when resting in bed. d. Avoid the use of cold packs because they will exacerbate the muscle spasms.

ANS: C Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. Prolonged standing will cause strain on the lumbar spine, even with both feet flat on the floor. Alternate application of cold and heat can be used to decrease pain

15. After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. What action would the nurse take? a. Elevate the right leg on two pillows. b. Obtain vital signs for indication of hemorrhage. c. Review the preoperative assessment data in the health record. d. Turn the patient to the left to relieve pressure on the right leg.

ANS: C The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient or elevating the leg will not relieve the numbness.

2. Which information would the nurse include when teaching a patient with acute low back pain? (Select all that apply.) a. Sleep in a prone position with the legs extended. b. Keep the knees straight when leaning forward to pick something up. c. Expect symptoms of acute low back pain to improve in a few weeks. d. Avoid activities that require twisting of the back or prolonged sitting. e. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

ANS: C, D, E Acute back pain usually starts to improve within 2 weeks. In the meantime, the patient should use medications such as nonsteroidal antiinflammatory drugs (NSAIDs) or acetaminophen to manage pain and avoid activities that stress the back. Sleeping in a prone position and keeping the knees straight when leaning forward will place stress on the back and should be avoided.

14. A patient has had surgical reduction of an open fracture of the right radius. Which assessment findings would the nurse report immediately to the health care provider? a. Serous wound drainage b. Right arm muscle spasms c. Pain with right arm movement d. Temperature 101.4F (38.6C

ANS: D An elevated temperature suggests possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.

13. What information would the review to evaluate the effectiveness of alendronate (Fosamax) therapy for a patient with Paget's disease? a. Oral intake b. Grip strength c. Hemoglobin level d. Alkaline phosphatase

ANS: D Bisphosphonate drugs are used to slow bone resorption. Monitor drug effectiveness by regular assessment of alkaline phosphatase. Oral intake, hemoglobin level, and grip strength information will be collected by the nurse but will not be used in evaluating the effectiveness of this therapy.

11. A 54-yr-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia. Which information would the nurse explain to the patient? a. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. b. Estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. c. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. d. Calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.

ANS: D Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy is not routinely given to prevent osteoporosis because of increased risk of heart disease as well as breast and uterine cancer. Corticosteroid therapy increases the risk for osteoporosis.

12. Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? a. Pancakes with syrup and bacon b. Whole wheat toast and fresh fruit c. Egg-white omelet and a half grapefruit d. Oatmeal with skim milk and fruit yogurt

ANS: D Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods.

9. Which statement by a patient with discomfort from a bunion indicates to the nurse that more teaching is needed? a. "I will give away my high-heeled shoes." b. "I can take ibuprofen (Motrin) if I need it." c. "I will use the bunion pad to cushion the area." d. "I can only wearsandals, no closed-toe shoes."

ANS: D The patient can wear shoes that have a wide forefoot (toe box). The other patient statements indicate the teaching has been effective.