EXAM 4 CHA2 practice questions
Chronic Osteomyelitis RF
-Long-Term IV Catheters can be the primary source of infection. (Hemodialysis, IV Drug Users, Salmonella Infection in GI, Sickle Cell Patients, Poor Dental Hygiene, and Penetrating Trauma.)
Epilepsy diagnosis
2 or more seizure in a lifetime- secondary does not count
What is a TIA? How is it a risk factor for strokes?
A TIA is a temporary neurologic dysfunction resulting from a brief interruption in cerebral blood flow. Common cause of a stroke is decreased blood flow to the brain, which makes having a TIA a warning sign for a possible ischemic stroke.
Cushings triad
A classic late sign of Increases ICP with severe hypertension, wide pulse & pressure and bradycardia. Normally indicates imminent death due to herniation
What are critical take-aways to remember about the GCS?
A decrease of 2 or more points total is clinically significant and needs to be communicated to the provider immediately! Sudden subtle changes in mental status-changes in level of consciousness are the earliest sign of neurological deterioration. New finding of abnormal flexion or extension-(decerebrate or decorticate posturing) Pinpoint or dilated nonreactive pupils
The nurse asks the unlicensed assistive personnel (UAP) to obtain vital signs for the patient with osteomyelitis. Which of the following results would the nurse expect to be reported immediately by the UAP?
A fever is a systemic sign of inflammation and infection. This patient may need antibiotic therapy. The other vital signs are normal or high normal.
Following an open reduction and internal fixation of a tibia fracture, what is most essential for the nurse to do?
A neurovascular assessment will identify early signs of compartment syndrome, a risk after a musculoskeletal fracture, injury or surgery. Compartment syndrome impairs neurovascular function to the extremity and could lead to permanent damage. Neurovascular assessment includes assessing for the 6 P's (and you'll need to know them): pain, pallor, paresthesia, pressure, paralysis and pulselessness. Assess both legs for symmetry, comparing one with another. There may not be pins present and the neurovascular assessment is priority. Ambulation should occur only if prescribed and the neurovascular status is within normal limits. An abduction pillow is used for hip replacement surgery (arthroplasty) but not for ORIF.
Should the patient with a hemorrhagic stroke take daily aspirin?
A patient with an acute hemorrhagic stroke should not be taking any anticoagulants. The associated risk of further stroke is typically managed with antihypertensives, statins, and non-pharmacological interventions. After the stroke has resolved, then a daily anticoagulant may be initiated.
Myasthenia gravis
An acquired autoimmune disease characterized by progressive muscle weakness.Two types are ocular and generalized. It is caused by distorted acetylcholine receptors in the muscle motor end plate membranes. As a result, nerve impulses are reduced in the neuromuscular junction;they don't result in muscle contraction. It may range from mild disturbances of the cranial/peripheral motor neurons to a rapidly developing generalized weakness that may result in death from respiratory failure.
Left Hemisphere
Aphasia, agraphia, alexia Possible deficit Inability of discriminate words and letters; reading problems; deficits in the right visual field; cortical blindness Slowness; cautiousness; anxiety when attempting a new task; depression or a catastrophic response to illness No deficit (hearing)
What are the priority assessments and time frame to provide this for a stroke patient that presents to an ED?
Assess the stroke patient within 10 minutes of arrival to the ED, nurses priority assessments include ABCs and should perform complete neurologic assessment using the NIHSS tool, Glasgow Coma scale, and a STAT CT to evaluate for possible ischemia or areas of decreased perfusion. The patient should then be admitted to a specialized stroke unit who are experts in acute stroke assessment and management. The Glasgow coma scale is also used to monitor for changes in LOC throughout the patients acute care.
epidural hematoma
Bleeds faster than subdural hematoma because it is an arterial bleed vs a venous bleed
Osteoblasts
Bone building cells
Osteoclasts
Bone-destroying cells
How to reposition spinal cord injuries
C spine precautions & log rolling
Parkinson's meds
Carbidopa/Levodopa Indications: Antiparkinson agent The body metabolizes Levodopa to produce dopamine. Giving dopamine directly is ineffective because the brain's natural defense blocks it from being used by the body. To suppress nausea and other possible side effects, carbidopa is used in tandem with it.
A patient is seen with rheumatoid arthritis who is on celecoxib. What health teaching should the nurse provide?
Celecoxib (Celebrex) is an NSAID, more specifically a COX-2 inhibitor. This class of drug can cause severe GI symptoms, bleeding, and acute renal failure, particularly in the elderly. They may increase risk of cardiovascular disease. Signs and symptoms that these drugs are not tolerated include frequent indigestion, hematemesis, dark, tarry stools, edema, shortness of breath, or oliguria. If these symptoms are noted, the client should contact the healthcare provider immediately. Taking the medication with food, such as with breakfast, may increase the tolerance.
How can the nurse best help prepare a patient with an amputation for prosthesis and encourage mobility?
Collaborate with PT and OT to begin exercises ASAP after surgery. If the amputation is planned, muscle strengthening exercises may start before surgery, and pt can practice with ambulatory aids. Teach ROM exercises to prevent flexion contractures. A trapeze over the bed may help strengthen muscles and allow for the patient to move independently in bed. Teach the patient to turn every 2 hours and move slowly to prevent muscle spasms. A firm mattress can help prevent contractures. Teach the patient how to push the residual limb down toward the bed while supporting it on a soft pillow at first. Then progress to a firmer pillow and then to a hard surface. This activity helps prepare for prosthesis and reduce incidences of phantom limb pain. Inspect residual limb daily to ensure it lies completely flat on the bed. Before amputation the patient will see a certified prosthetist-orthotist (CPO) to plan for post-op. Some patients are fitted with a temporary prosthesis at the time of surgery, others (particularly older patients with vascular disease) are fitted once the residual limb has healed. If being fitted for a leg prosthesis, bring a sturdy pair of shoes to the fitting. The prosthesis will be adjusted to that heel height. Several devices can be used to help shape and shrink the residual limb to prepare for prosthesis. Rigid, removable dressings are preferred because they decrease edema, protect and shape the limb, and allow easy access to the wound for inspection. Other options are air splints and wrapping with elastic bandages. For wrapping to be effective, reapply the bandages every 4-6 hours or more if they become loose. Figure 8 wrapping prevents restriction of blood flow. Decrease the tightness of bandages while wrapping in a distal to proximal direction. After wrapping, anchor the bandages to the highest joint.
When caring for a patient with a femur fracture, which of the following symptoms if reported by the UAP is most significant?
Confusion is the most significant abnormality and should be reported. An early symptoms of fat emboli in the fracture patient may be confusion or alteration in mental status. This is due to low arterial oxygen level. The nurse would want to know about a patient's pain and treat the pain but it is not a life-threatening issue. The nurse would also want to know about the patient's blood pressure and voiding but neither is urgent to report.
Sensorineural hearing loss
Damage or defect to the cochlea, 8th cranial nerve or the brain. Exposure to loud noises or music damages the cochlear hair and causes hearing loss
What are priority problems for patients with stroke?
Depending on location and severity of stroke all of our primary airway/breathing/circulation/safety can be problems. Aspiration, falls, aneurysm and additional strokes, and general decreased function are all common problems related to strokes and cover the spectrum of major system problems.
MD education
Discussion regarding the specific form of muscular dystrophy, including the treatment. Patient and family must understand that disease is progressive and there is no cure. Emphasis use of assistive devices to maintain function and independence. Depending on the form of muscular dystrophy, serious complications may occur, including arrhythmias, dysphagia and seizures. Patients are more prone to respiratory infections, must emphasize coughing and deep breathing exercises. Education that includes an adequate diet, with emphasis on high fiber foods to avoid constipation.
Discharge instructions for cast care to include:
Do not get the cast wet, keep it free from dirt or sand, and do not make adjustments yourself by removing padding or even a portion of the cast itself. We also need to educate regarding items of concern or when to contact the provider. These items include reporting any feelings of increased pain, numbness, tingling, burning, or swelling under the cast. If the patient has an inability to move fingers/toes, or if they become blue or cold, red or raw, develop cracks, or experience a foul odor the patient needs to contact their provider as these could indicate signs of decreased perfusion or infection.
Wernicke's aphasia
Due to injury in the temporal parietal lobe. A patient cannot understand spoken word.
Fat embolism signs and symptoms
Earliest manifestation is altered mental status, caused by low arterial 02 level. Dyspnea and chest pain follow. Petechiae, a macular rash, may appear over neck, upper arms, or chest & abdomen
open angle glaucoma signs and symptoms
Early- foggy vision at times, mild eye aching or headaches Late- halos around lights, loss of peripheral vision, decreased sight uncorrectable with glasses, increase IOP
Ménière's disease
Excess of endolymphatic fluid, which distorts the inner-canal system. Thus decreasing hearing by dilating the cochlear duct. Causes vertigo because of the damage to the vestibular system, and will also cause tinnitus. (Initially the hearing loss is reversible but after multiple attacks it becomes irreversible from permanent damage to cochlea) *****dizziness with a spinning sensation, feeling, unsteady
Medications glaucoma
Eye drops, beta blockers, cholinergic agonist, prostaglandin agonists, carbonic anhydrase inhibitors,- si adrenergic agonists.
Stroke Priority nursing concerns/interventions:
First priority is to ensure the patient is transported to a stroke center! GET CT STAT Monitor for increased intracranial pressure; most at risk resulting from edema during first 72 hours from onset of stroke elevated HOB to improve perfusion pressure Oxygen therapy: Hyperoxygenate before/after suctioning to avoid transient hypoxemia Closely monitor BP, heart rhythm, O2 sats, glucose, body temp Maintain head in a midline, neutral position Avoid sudden and acute hip or neck flexion during positioning Avoid clustering of nursing procedures Provide airway management Maintain quiet environment, keep room lights low
What pharmacological treatments may be used for a person with osteoporosis?
For those older than 50 and postmenopausal women, HCP may prescribe calcium and vitamin D supplements, bisphosphonates, estrogen agonist/antagonists, parathyroid hormone, RANKL inhibitor, and combination of drugs.
Gout
Gout is a form of osteoarthritis in which pain and severe joint inflammation occur when too much uric acid crystallizes and deposits in the joints, mainly affecting the big toe.
Glaucoma Assessment
Headache or brow pain, Nausea and vomiting, Colored halos around lights, Sudden blurred vision with decreased light perception. Visual acuity in both eyes. Assess home for safety hazards, Tonometry- ocular pressure (normal 10-21), Perimetry- visual field testing, Gonioscopy-visualization of the chamber angle(differentiates between glaucomas), Optic nerve imaging- any nerve involvement
cataracts assessment
History (age, recent/old trauma, systemic disease, medications [corticosteroids], eye disease, family history, exposure to toxic chemicals, etc.), ask patient to describe vision, blurred/double vision, decreased color perception, anxiety about loss of independence - NO pain or redness should be present
What is the IV therapy used for treatment for a patient following an ischemic stroke?
IV Fibrinolytic therapy (alteplase) to bust the clot and improve blood flow to viable tissue and the brain.
Right Hemisphere
Impaired sense of humor Disorientation to time, place, person; inability to recognize faces Visual spatial deficits; neglect of the left visual field; loss of depth perception; cortical blindness Impulsiveness; lack of awareness of neurologic deficits; confabulation; euphoria; constant smiling; denial of illness; poor judgment Loss of ability to hear tonal variations
What are some other nursing interventions during the acute phase following stroke?
Interventions are primarily determined by the type and extent of the stroke. Monitor for neurologic changes, administer IV fibrinolytic therapy, ongoing supportive care, prevent patient falls. Perform neurologic assessments including VS every 10-15 minutes during the infusion of tPA and every 30minutes after that for at least 6 hours. Administer antihypertenisve if appropriate Prevent bleeding do not place invasive tubes such as NG and indwelling catheters until patient has been stable for 24 hours Discontinue infusion if patient reports severe headache or has severe HTN, bleeding, N/V and notify the HCP Obtain CTA/CTP scan after fibrinoltyic and before starting antiplatelet/anticoagulation therapy
TPA
Ischemic stroke Within 3 hours of onset of symptoms
Cast immobilization-
It is a rigid device that immobilizes the affected body part while allothing other body parts to move. It allows for early mobility and reduces pain. can be used for correction of deformities like RA. Fiberglass is most commonly used for fracture immobilization. It is a waterproof synthetic casting material. The cast can be too tight and impair adequate blood flow. Nursing management inspect the cast once every 8-12 hours for drainage, alignment, and fit. Complications: infection, circulation impairment, peripheral nerve damage osteoarthritis and osteoporosis. Assessing for pain and warmth in the area that you suspect the patient is having the complication. Osteoarthritis and osteoporosis may develop due to lack of bearing weight and muscle atrophy due to prolonged immobilization.
The patient who just returned from a right above-the-knee amputation complains that his right great toe is very painful. How should the nurse respond?
Many amputees experience phantom limb pain. Acknowledge that the pain is real and handle the surgical area carefully. Opioid narcotics are helpful for surgical pain but not phantom limb pain. Always assess the type of pain the patient is experiencing and treat surgical site pain accordingly. The nurse should not tell the patient the limb is gone and the pain isn't real. This is not therapeutic. The residual limb is often elevated for a short time after surgery and allowing the limb to be lowered will increase post-op edema.
Neurogenic Shock-
Monitor for SpO2 <95 with symptoms of aspiration Symptomatic bradycardia, reduced LOC and decreased urine output Hypotension and systolic BP <90 or mean arterial pressure (MAP) <65 NOTIFY PROVIDER IMMEDIATELY
Glaucoma
Open Angle Glaucoma: Blockage of the trabecular meshwork slows drainage of the aqueous humor, which increases intraocular pressure. Angle-closure glaucoma: acute glaucoma, considered emergent, Iris is displaced. Sudden change of outflow of aqueous humor. Caused by-Increased ocular pressure or cupping and atrophy of optic disc.
glaucoma dx
Ophthalmoloscopic examination and tonometry which measures pressure
Teaching for migraines
Pain management is the priority intervention for those with migraines, Take meds as described
What are overall nursing priorities for phantom pain
Pain management, if the patient reports pain, recognizes that the pain is REAL and should be managed promptly and completely! IV infusions of calcitonin during the week after amputation can reduce PLP Beta-blocking agents, propranolol, used for constant, dull, burning pain Antiepileptic drugs, pregabalin or gabapentin, used for knifelike or sharp burning (neuropathic) pain Safety, help patient feel supported to reduce the risk of them trying something unsafe
The home care nurse visits a client with rheumatoid arthritis. The client states he often has a lot of pain in the morning and some days are worse than others. What information should the nurse share with the client and her family? (Select all that apply.)
Patients with rheumatoid arthritis often experience more stiffness and pain in the morning. A hot shower is often helpful to relieve these symptoms. Patients should always complete their prescribed exercises each day, whether experiencing more pain or less. When pain is more severe, fewer repetitions may be done. Additionally, resistance exercises should be avoided when joints are severely inflamed. Active rather than passive exercises should be done whenever possible. Normal daily activities and household chores should not replace the prescribed exercises.
A nurse is caring for a child with an external fixation device on a fractured leg. What is the nurse's priority goal when providing pin care?
Pin sites provide a direct route for organisms to enter the bone. Pin site care is a priority in infection prevention. Pin site care will not alter pain. Some scarring may occur but this can't always be preventing and is not a priority. Preventing infection will also help in preventing skin breakdown. The cause of any skin breakdown at pin sites would be infection.
muscular dystrophy (MD) medication
Prednisone: improves muscle strength/weakness and pulmonary function- side effects of prednisone: leeches ca+ from bones, causes immunosuppression - Anticonvulsants: decreases muscle spasms and seizure control - Immunosuppressants: delays muscle cell damage - stool softeners
Assessment of Parkinson's
Progressive neurological disease. Cardinal symptoms are tremor, muscle rigidity, bradykinesia, and postural instability. Acetylcholine produces excitatory messages, dopamine inhibits these messages, allowing control over voluntary movement, allowing coordinated, refined, movement. When the substantia nigra (where dopamine is produced) degenerates, dopamine levels are decreased and the ability to have refined, voluntary movements is los
Purpose of traction
Provide reduction & alignment of the fractured bone (most important) and reduce muscle spasms
Multiple sclerosis
Random/ patchy areas of plaque replace the healthy myelin resulting in loss of transmission of impulses
What are some acute nursing interventions for the patient with a stroke?
Rapid identification via physical symptoms, immediate CT to determine type/location/severity, t-PA if applicable for ischemic strokes, permissive hypertension or antihypertensives depending on provider orders, SCDs, IV fluids, strict NPO, and many more options.
Which statement by the person with osteoporosis indicated the need for further teaching?
Risk factors for osteoporosis include age, family history, thin build, lack of exercise, smoking, alcohol and low intake of calcium and vitamin D. Patients with osteoporosis are more prone to fractures from even small amounts of trauma. Safety measures should be taken to limit obstacles that could lead to fall, such as throw rugs and clutter in the home.
Migraine meds
Severe migraine: Triptans take as soon as migraine starts. Activate serotonin receptors to produce vasoconstrictive effect. May cause chest pain. Rebound headaches.
Describe how the nurse should teach the FAST pneumonic to a patient and their family.
Teach family members to observe for signs of a new stroke using the FAST mnemonic: • Face drooping • Arm weakness • Speech or language difficulty • Time to call 911
Traction
The application of a pulling force to a part of the body to provide reduction, realignment, and rest. Keep the bone in proper alignment without casting or splinting limbs. Could help prevent deformities, muscle spasms, and tissue damage. Complications in skeletal traction could be osteomyelitis, so nurses want to ensure there is good pin site care (the point where pins are inserted and have direct contact with bone) Nurses are not allowed to change the weight, this is done through prescription.
A patient has returned from the post-anesthesia care unit after a lumbar discectomy and requests to turn in bed. How should the nurse assist the patient to turn?
The patient after a back surgery should be turned by logrolling. Logrolling will maintain correct body alignment. Twisting the body when turning could create misalignment of the spine and will create more pain in the postoperative period. To ensure proper healing, the spinal column must remain in alignment when the patient turns or moves.
A patient is treated for a fractured right tibia. Closed reduction is completed and a cast applied. The healthcare provider prescribes morphine sulfate 2 mg IV every 2 hours. Approximately ½ hour after medication, the patient complains of severe pain and tightness under the cast and numbness of the toes. What actions should the nurse take? (Select all that apply.)
The patient is having symptoms of compartment syndrome with ischemia of the tissue. This is not normal. Repositioning of the cast is not enough. The cast should not be readjusted and should not fit snugly against the site of fracture. Neurovascular checks must be performed, assessing for the 6 P's. Loosen or remove restrictive items. The cast may need to be cut (bivalve the cast). Notify the provider. Although elevation will decrease edema in most situations, in this case, ischemia could be worsened by elevation. Do not apply ice to the area as it also will further reduce perfusion.
3. After receiving the change-of-shift report, which patient should you assess first?
The patient with the tight cast is at risk of circulation impairment and peripheral nerve damage. Compartment syndrome may be developing. Although the other patients' concerns are important, none of them is as urgent as the tight cast.
What precautions must be taken for the patient who has had a right total hip arthroplasty? (Select all that apply.)
The patient's hip must be kept in good alignment and adduction must be avoided along with twisting of the body. Also, bending the hip more than 90 degrees must be avoided to prevent dislocation. Rehab may start soon after surgery and may continue for a few weeks. Depending on the type of prosthesis, most patients can begin with toe-touch weight bearing or partial weight bearing soon after the surgery.
What are considerations that the nurse needs to keep in mind in regards to the family of a stroke patient for chronic management at home?
The signs and symptoms of depression that may occur within 3 months after a stroke Lifestyle changes, drug therapy, ambulation/transfer skills, communication skills, safety precautions, nutritional management, activity levels, and self- management skills
What is the most important consideration in whether or not rtPA can be used to treat ischemic stroke?
The time between the onset of symptoms and the time they are seen at the ED/stroke center. Currently the FDA approves administering alteplase within 3 hours of stroke onset while American Stroke Association extended the time frame to 4.5 hours unless they fall into specific categories. If more than time has passed, there is likely too much brain damage and the benefits should outweigh the risk of administering. Newest recommendation is the patient should be given fibrinolytic is 45 minutes from the time they arrive at the ED.
The nurse is caring for a patient in skeletal traction. Which of the following assessments would indicate a need for nursing action?
The weights should not rest on the floor or no resistance is placed on the bone. The other items are appropriate.
A patient is at risk for compartment syndrome after a traumatic leg injury. What changes must the nurse monitor for if the syndrome does develop? (Select all that apply)
Through neurovascular assessment, the nurse must watch for the 6 P's: pain, pallor, pulselessness, paralysis and pressure. As edema develops in the extremity, the pressure rises and blood flow will diminish in addition to compression on nerves.
Parkinson's disease signs and symptoms
Tremors, muscle rigidity, bradykinesia or akinesia, postural instability
vagus nerve stimulator
Vagus nerve stimulator may be placed, then patients can hold a magnet over the implant when they feel an aura Seizure precautions (to prevent injury if seizure happens): bed in low position, all side rails up oxygen and suction at the bedside, IV access, equipment to secure patient's airway
Autonomic Dysreflexia
When noxious stimulation to organs or skin cause a sudden severe increase in systolic blood pressure that can lead to a hemorrhagic stroke. Sit the patient up, check clothing and equipment for tightness, check for bowel impaction
What is a T- Score and why could it lead to a fracture?
Your T-score is your bone density compared to what is normally expected for a healthy person of your age and sex. This score tests to see if your bone density is above or below average. The lower T-score, the more weak the bones are, and the more likely they are to break. Health 30 year old T=0 Osteopenia T= -1 to -2.49 Osteoporosis T= at or lower than -2.5
Medication Siezures
active seizures: IV lorazepam, ; rectal diazepam (Antiepileptic/Anticonvulsant/Benzodiazepine Drug Class) prevention: Dilantin (Phenytoin); Levetiracetam (Keppra); Valproic Acid
Signs and symptoms of cataracts
blurring, diplopia, photophobia, cloudy lens
Osteoarthritis patient education
care for affected joints, safety ( avoid falls, use walkers, canes etc.) use large joints, use two hands to hold objects, sit in a chair with a high straight back, do not bend at the waist. use long handheld devices such as a hairbrush etc.
Spinal shock-
complete but temporary loss of motor, sensory, reflex, and autonomic function that often lasts less than 48 hours but may continue for several weeks.
What is Autonomic Dysreflexia
first priority: place the patient in a sitting position or return to previous safe position, then call the PCP or Rapid Response. Treat the cause, and cath full bladder to relieve urinary retention life-threatening condition in which noxious visceral or cutaneous stimuli cause a sudden, massive, uninhibited reflex sympathetic discharge in people with a high-level SCI. sudden, significant rise in systolic and diastolic pressure bradycardia, profuse sweating, goosebumps, blurred vision, seeing spots, nasal congestion, headache, and feeling apprehension.
Compartment syndrome
involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles Complication of fracture
What are the components of a neurovascular assessment of musculoskeletal injury, and for what manifestations of musculoskeletal alterations is the nurse assessing (6Ps)?
pain, pressure, paralysis, paresthesia, pallor, and pulselessness.
What are the generalized signs and symptoms of fractures in children?
pain, tenderness, deformity, decreased ROM, swelling, crepitus, ecchymosis, erythema, muscle spasm, inability to bear weight.
Spinal shock
physiologic response that occurs between 30 and 60 minutes after trauma to the spinal cord and can last up to several weeks. spinal shock presents with total flaccid paralysis and loss of all reflexes below the level of injury.
Fat Embolism Syndrome (FES)
serious complication of fractures in which fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury. These fat globules clog small blood vessels that supply vital organs, such as lungs, and impair organ perfusion. ***usually result from fractures or fracture repair but may also occur in patients experiencing pancreatitis, osteomyelitis, blunt trauma, or sickle cell disease.
Acute Compartment Syndrome (ACS)
serious, limb-threatening condition in which increased pressure within one or more compartments (areas in the body where muscles, blood vessels, and nerves are contained with fascia) reduces circulation to the area. This increased pressure can be caused by internal (blood/fluid accumulation) or external (tight dressings, casts) sources. ACS can lead to infection, motor weakness, contracture, myoglobinuric renal failure, and potentially amputation.
Specific considerations for home Care for Child in a cast:
watch for things to go into cast as kids like to hide toys assess for unusual odors elevate on pillow for 24 hours do not put things into to scratch itches
What are the types of radiological screening and diagnostic tests for measuring bone mineral density?
xrays-of the spine and long bones can show bone density, but only after a large amount of bone loss has occurred. Most common is DXA or DEXA scan. Recommended that women in their 40's have baseline scans complete CT based absorptiometry-measures volume of bone density and strength of the vertebral spine and hip. Vertebral imaging. MRI for bone marrow composition.
