Chapter 63: Musculoskeletal Problems

The nurse has reviewed proper body mechanics with a patient who has a history of low back pain caused by a herniated lumbar disc. Which patient statement indicates a need for further teaching?

"I should pick up items by leaning forward without bending my knees." Rationale: The patient should avoid leaning forward without bending the knees. Bending the knees helps to prevent lower back strain and is part of proper body mechanics for lifting. Sleeping on the side or back with hips and knees bent and standing with a foot on a stool will decrease lower back strain. Back strengthening exercises are done twice a day once symptoms subside.

A patient with osteomyelitis is to receive vancomycin (Vancocin) 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 should set the IV pump to deliver how many milliliters per minute? (Round to the nearest hundredth.)

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

The nurse is caring for patients in a primary care clinic. Which patient is most at risk to develop osteomyelitis caused by Staphylococcus aureus?

A 32-yr-old male patient with type 1 diabetes and stage 4 pressure injury Rationale: Osteomyelitis caused by S. aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices from joint arthroplasty. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.

The nurse provides instructions to a 30-yr-old office worker who has low back pain. Which statement indicate additional patient teaching is required?

Acupuncture to the lower back would cause irreparable nerve damage." Rationale: Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic purposes.

The nurse is admitting a patient with a history of a herniated lumbar disc and low back pain. Which action would likely aggravate the pain?

Bending or lifting Rationale: Back pain related to a herniated lumbar disc is aggravated by events and activities that increase stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc.

A 24-yr-old male patient has come to the clinic with a gradual onset of pain and swelling in the left knee. The patient is diagnosed with osteosarcoma without metastasis. Chemotherapy is ordered before surgery. How would the nurse explain the reason for preoperative chemotherapy?

Chemotherapy is being used to decrease the tumor size." Rationale: Preoperative chemotherapy is used to decrease the tumor size before surgery. The chemotherapy will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct chemotherapy after amputation or limb salvage has increased 5-year survival rates in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery.

The nurse is admitting a patient who reports the new onset of lower back pain. To distinguish between the pain of a lumbar herniated disc from other causes, what is the best question for the nurse to ask the patient?

Does the pain radiate down the buttock or into the leg?" Rationale: Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve. It is often described as traveling through the buttock to the posterior thigh or down the leg. This is because the herniated disc causes compression on spinal nerves as they exit the spinal column. Time of occurrence, type of pain, and pain relief questions do not elicit differentiating data.

patient who has low back pain from a herniated lumbar disc is having muscle spasms. Which nursing intervention would be most appropriate?

Elevate the head of the bed 20 degrees and flex the knees. Rationale: To reduce pain, the nurse should elevate the head of the bed 20 degrees and have the patient flex the knees to avoid extension of the spine. The slight flexion provided by this position often is comfortable for a patient with a herniated lumbar disc. ROM to the lower extremities will be limited to prevent extremes of spinal movement. Reverse Trendelenburg and a pillow under the patient's upper back will more likely increase pain.

The nurse is reinforcing health teaching about osteoporosis with a 72-yr-old patient admitted to the hospital. What should the nurse explain to the patient?

Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. Rationale: The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer.

A patient with acute osteomyelitis asks the nurse how this problem will be treated initially. Which response by the nurse is most appropriate?

IV antibiotics are usually required for several weeks." Rationale: The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. However, as many as 3 to 6 months may be required. Bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all microorganisms. Surgery may be used for chronic osteomyelitis, to include debridement of the devitalized, infected tissue and irrigation of the affected bone with antibiotics.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. When completing a focused assessment, which symptom should the nurse expect?

Localized pain and warmth Rationale: Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized rather than generalized throughout the leg.

An older adult is diagnosed with Paget's disease. Which finding would indicate improvement in the condition?

Lower serum alkaline phosphatase Rationale: Paget's disease is characterized by excessive bone resorption and replacement of normal marrow with vascular, fibrous connective tissue. A normalizing alkaline phosphatase indicates bone resorption has slowed or stopped. Additional characteristics of the disease include bone pain, a waddling gait, loss of stature, and curved bones. Uptake of radiolabeled bisphosphonate indicates a bone is affected.

During a health screening event, which assessment finding in a 61-yr-old patient would alert the nurse to the possible presence of osteoporosis?

Measurable loss of height Rationale: A gradual but measurable loss of height and the development of kyphosis ("dowager's hump") are indicative of the presence of osteoporosis. Bowed legs may be caused by abnormal bone development or rickets but are not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative of its presence. A wide gait is used to support balance and does not indicate osteoporosis.

A 58-yr-old woman with breast cancer is admitted for severe back pain related to a vertebral compression fracture. The patient's laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms would the nurse expect the patient to exhibit?

Nausea, vomiting, and altered mental status Rationale: Breast cancer can metastasize to the bone, with vertebrae as a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium results as calcium is released from damaged bones. Normal serum calcium is 8.6 to 10.2 mg/dL. Manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include muscle stiffness, dysphagia, and dyspnea.

A 67-yr-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges and elevation of the affected foot on 2 pillows. The nurse would place the highest priority on which intervention?

Perform frequent position changes and range-of-motion exercises. Rationale: The patient is at risk for atelectasis of the lungs and contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest. Dangling the legs every 2 to 4 hours may be too painful.

Which nursing intervention is most appropriate when turning a patient after spinal surgery?

Placing a pillow between the patient's legs and turning the body as a unit Rationale: Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort after spinal surgery. The other interventions will not maintain proper spine alignment and may cause spinal damage.

When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching plan?

Remain active to prevent skin breakdown and respiratory complications. Rationale: With muscular dystrophy, the patient must remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP) may be used as respiratory function decreases before mechanical ventilation is needed to sustain respiratory function.

The nurse determines dietary teaching for a 75-yr-old patient with osteoporosis has been successful when the patient selects which meal as highest in calcium?

Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk Rationale: The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium but not as much as the sardines, yogurt, and milk.

The nurse is planning health promotion teaching for a 45-yr-old patient with asthma who has low back pain from herniated lumbar disc. What activity would the nurse include in an individualized exercise plan for the patient?

Walking Rationale: The patient would benefit from an aerobic exercise that considers the patient's health status and fits the patient's lifestyle. The best exercise is walking, which builds strength in the back and leg muscles without putting undue pressure or strain on the spine. If the patient has exercise-induced asthma, the nurse would recommend use of a rescue inhaler prior to exercise. Yoga, calisthenics, and weightlifting would all put pressure on or strain the spine.

Which actions should 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. 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. 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 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.

In which order should the nurse implement interventions prescribed for a patient admitted with acute osteomyelitis who has a temperature of 101.2° F?

a. Obtain blood cultures from two sites. b. Administer dose of gentamicin 60 mg IV. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever. c. Send to radiology for computed tomography (CT) scan of right leg The highest treatment priority for osteomyelitis is initiation of antibiotic therapy, but cultures should be obtained before administration of antibiotics. Addressing the discomfort of the fever is the next highest priority. Because the purpose of the CT scan is to determine the extent of the infection, it can be done last.

Which action should the nurse take when caring for a patient with osteomalacia?

a. Teach about the use of vitamin D supplements. Osteomalacia is caused by inadequate intake or absorption of vitamin D. Weight-bearing exercise and bisphosphonate administration may be used for osteoporosis but will not be 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.

A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective?

b. "I will begin doing exercises to strengthen and support my back." 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.

Which action should the nurse take first when a patient is seen in the outpatient clinic with neck pain?

b. Ask about numbness or tingling of the hands and arms. The nurse's initial action should 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.

What action should the nurse complete before administering alendronate (Fosamax) to a patient with osteoporosis?

b. Assist the patient to sit up at the bedside. 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.

A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action should the nurse include in the plan of care?

b. Assist the patient with ambulation. 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.

A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information should the nurse include in the discharge teaching?

b. How to monitor and care for a long-term IV catheter The patient will be taking IV antibiotics for several months. The patient will need to recognize signs of infection at the IV site and know how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.

A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention should the nurse include in the initial plan of care?

b. Immobilization of the left leg 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. Flexion of the affected limb is avoided to prevent contractures.

Which assessment finding for a 55-yr-old patient should alert the nurse to the presence of osteoporosis?

b. Loss of height 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.

A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first?

b. Patient who has not voided 8 hours after a laminectomy. Difficulty in voiding may indicate damage to the spinal nerves and should 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

Which action should the nurse take when repositioning the patient who has just had a laminectomy and discectomy?

b. Place a pillow between the patient's legs and turn the entire body as a unit. The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.

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?

c. "I did not have this bone cancer until my leg broke a week ago." 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.

A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. Which statement by the patient should indicate to the nurse the need for additional teaching related to health maintenance?

c. "I think my left foot is starting to droop down." 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.

Which information should the nurse include when teaching a patient with acute low back pain? (Select all that apply.)

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. 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

What should the nurse include in the teaching plan for ae patient who has acute low back pain and muscle spasms?

c. Keep the head elevated slightly and flex the knees when resting in bed 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 should be used to decrease pain

Which action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

c. Log roll the patient from side to side every 2 hours. Repositioning a patient is included in the education and scope of practice of UAP, and experienced UAP 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.

After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. What action should the nurse take?

c. Review the preoperative assessment data in the health record. 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.

Which statement by a patient with discomfort from a bunion indicates to the nurse that more teaching is needed?

d. "I can only wear sandals, no closed-toe shoes." The patient can wear shoes that have a wide forefoot (toe box). The other patient statements indicate the teaching has been effective.

A 54-yr-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia. Which information should the nurse explain to the patient?

d. Calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise. Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy is no longer 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.

Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective?

d. Oatmeal with skim milk and fruit yogurt Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods.

What should the nurse assess to evaluate the effectiveness of alendronate (Fosamax) therapy for a patient with Paget's disease?

d. Pain intensity Bone pain is a common early manifestation of Paget's disease, and the nurse should assess the pain intensity to determine if treatment is effective. The other information will be collected by the nurse but will not be used in evaluating the effectiveness of the therapy.

Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis?

d. Review the patient's serum creatinine results. Gentamicin is nephrotoxic and can cause renal failure as reflected in the patient's serum creatinine. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.

A patient has had surgical reduction of an open fracture of the right radius. Which assessment findings should the nurse report immediately to the health care provider?

d. Temperature 101.4° F (38.6° C) An elevated temperature suggests possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.

The nurse receives report from the licensed practical nurse (LPN/VN) about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement?

he patient who had spinal surgery 3 hours ago is reporting a headache and has clear drainage on the dressing." Rationale: After spinal surgery, there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery, patients often wear a soft or hard cervical collar to immobilize the neck.