Lewis Chapter 62: Musculoskeletal Trauma and Orthopedic Surgery

The nurse is caring for a 76-year-old man who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects what to be included in the care of the affected leg? A Progressive leg exercises to obtain 90-degree flexion B Early ambulation with full weight bearing on the left leg C Bed rest for 3 days with the left leg immobilized in extension D Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation

A Progressive leg exercises to obtain 90-degree flexion Although early ambulation is not done, the patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible. Because this is painful after surgery, the patient requires good pain management and often the use of a CPM machine. The patient's knee is unlikely to dislocate.

A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate? A. "IV antibiotics are usually required for several weeks." B. "Oral antibiotics are often required for several months." C. "Surgery is almost always necessary to remove the dead tissue that is likely to be present." D. "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

A. "IV antibiotics are usually required for several weeks." The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Surgery may be used for chronic osteomyelitis, which may include debridement of the devitalized and infected tissue and irrigation of the affected bone with antibiotics

Musculoskeletal assessment is an important component of care for patients on what type of long-term therapy? A. Corticosteroids B. β-Adrenergic blockers C. Antiplatelet aggregators D. Calcium-channel blockers

A. Corticosteroids Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system.

A 72-year-old patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DXA) testing. The nurse will plan to a. explain the procedure. b. start an IV line for contrast medium injection. c. give an oral sedative 60 to 90 minutes before the procedure. d. screen the patient for allergies to shellfish or iodine products.

A. DXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Because the procedure is painless, no antianxiety medications are required.

The nurse is performing a musculoskeletal assessment of an 81-year-old female patient whose mobility has been progressively decreasing in recent months. How should the nurse best assess the patient's range of motion (ROM) in the affected leg? A. Observe the patient's unassisted ROM in the affected leg. B. Perform passive ROM, asking the patient to report any pain. C. Ask the patient to lift progressive weights with the affected leg. D. Move both of the patient's legs from a supine position to full flexion.

A. Observe the patient's unassisted ROM in the affected leg. Passive ROM should be performed with extreme caution and may be best avoided when assessing older patients. Observing the patient's active ROM is more accurate and safe than asking the patient to lift weights with her legs.

A patient has a new order for magnetic resonance imaging (MRI) to evaluate for left femur osteomyelitis after a hip replacement surgery. Which information indicates that the nurse should consult with the health care provider before scheduling the MRI? a. The patient has a pacemaker. b. The patient is claustrophobic. c. The patient wears a hearing aid. d. The patient is allergic to shellfish.

A. Patients with permanent pacemakers cannot have MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Because contrast medium will not be used, shellfish allergy is not a contraindication to MRI.

Which nursing intervention is most appropriate when turning a patient following spinal surgery? A. Placing a pillow between the patient's legs and turning the body as a unit B. Having the patient turn to the side by grasping the side rails to help turn over C. Elevating the head of bed 30 degrees and having the patient extend the legs while turning D. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed

A. Placing a pillow between the patient's legs and turning the body as a unit 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 following spinal surgery. Having the patient turn by grasping the side rail to help, elevating the head of the bed, and turning with extended legs or turning the patient's head and shoulders and then the hips will not maintain proper spine alignment and may cause damage.

In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.

ANS: C, D, B, E, A, F The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.

A patient with lower leg fracture has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching? a. "You will need to assess and clean the pin insertion sites daily." b. "The external fixator can be removed during the bath or shower." c. "You will need to remain on bed rest until bone healing is complete." d. "Prophylactic antibiotics are used until the external fixator is removed."

ANS: A Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.

A patient with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for an arthroplasty of the hand. Which patient statement to the nurse indicates realistic expectation for the surgery? a. "I will be able to use my fingers to grasp objects better." b. "I will not have to do as many hand exercises after the surgery." c. "This procedure will prevent further deformity in my hands and fingers." d. "My fingers will appear more normal in size and shape after this surgery."

ANS: A The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

When doing discharge teaching for a patient who has had a repair of a fractured mandible, the nurse will include information about a. when and how to cut the immobilizing wires. b. self-administration of nasogastric tube feedings. c. the use of sterile technique for dressing changes. d. the importance of including high-fiber foods in the diet.

ANS: A The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw.

Before assisting a patient with ambulation on the day after a total hip replacement, which action is most important for the nurse to take? a. Administer the ordered oral opioid pain medication. b. Instruct the patient about the benefits of ambulation. c. Ensure that the incisional drain has been discontinued. d. Change the hip dressing and document the wound appearance.

ANS: A The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

A patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures complains of constant severe pain in the leg, which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

ANS: A The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

A patient is seen at the urgent care center after falling on the right arm and shoulder. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The right arm appears shorter than the left. c. There is decreased range of motion of the shoulder. d. The patient is complaining of arm and shoulder pain.

ANS: B A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.

A patient who has a cast in place after fracturing the radius asks when the cast can be removed. The nurse will instruct the patient that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

ANS: B Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.

Which information obtained by the emergency department nurse when admitting a patient with a left femur fracture is most important to report to the health care provider? a. Bruising of the left thigh b. Complaints of left thigh pain c. Outward pointing toes on the left foot d. Prolonged capillary refill of the left foot

ANS: D Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.

A patient has hip replacement surgery using the posterior approach. Which patient action requires rapid intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull shoes and socks on. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing the teeth.

ANS: B Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

When planning care for a patient who has had hip replacement surgery, which nursing action can the nurse delegate to experienced nursing assistive personnel (NAP)? a. Teach quadriceps-setting exercises. b. Reposition the patient every 1 to 2 hours. c. Assess for skin irritation on the patient's back. d. Determine the patient's pain level and tolerance.

ANS: B Repositioning of patients is within the scope of practice of NAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.

When the nurse is caring for a patient who is on bed rest after having a complex pelvic fracture, which assessment finding is most important to report to the health care provider? a. The patient states that the pelvis feels unstable. b. Abdominal distention is present and bowel tones are absent. c. There are ecchymoses on the abdomen and hips. d. The patient complains of pelvic pain with palpation.

ANS: B The abdominal distention and absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

The nurse is preparing to assist a patient who has had an open reduction and internal fixation (ORIF) of a hip fracture out of bed for the first time. Which action should the nurse take? a. Use a mechanical lift to transfer the patient from the bed to the chair. b. Check the postoperative orders for the patient's weight-bearing status. c. Avoid administration of pain medications before getting the patient up. d. Delegate the transfer of the patient out of bed to nursing assistive personnel (NAP).

ANS: B The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given, since the movement is likely to be painful for the patient. The RN should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

A patient who has been hospitalized for 3 days with a hip fracture has sudden onset shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer the prescribed PRN oxygen at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

ANS: B The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.

A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in a dependent position. b. handle the cast with the palms of the hands. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

ANS: B Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

After a patient with a left femur fracture has a hip spica cast applied, which nursing intervention will be included in the plan of care? a. Avoid placing the patient in the prone position. b. Use the cast support bar to reposition the patient. c. Ask the patient about any abdominal discomfort or nausea. d. Discuss the reasons for remaining on bed rest for several weeks.

ANS: C Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.

When counseling an older patient about ways to prevent fractures, which information will the nurse include? a. Tack down scatter rugs in the home. b. Most falls happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Range-of-motion exercises should be taught by a physical therapist.

ANS: C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

After a patient has a short-arm plaster cast applied in the emergency department, which statement by the patient indicates a good understanding of the nurse's discharge teaching? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site for the next 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

ANS: C Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

A patient who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers on the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

ANS: C The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.

ANS: D A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the left femur? a. Assess for hip contractures. b. Monitor for hip dislocation. c. Check the peripheral pulses. d. Ask about left hip pain level.

ANS: D Buck's traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.

When giving home care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include? a. Keep the hand immobile to prevent soft tissue swelling. b. Keep the right shoulder elevated on a pillow or cushion. c. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the first 48 hours after the injury. d. Call the health care provider for increased swelling or numbness.

ANS: D Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.

A patient is admitted to the emergency department with possible left lower leg fractures. The initial action by the nurse should be to a. elevate the left leg. b. splint the lower leg. c. obtain information about the tetanus immunization status. d. check the popliteal, dorsalis pedis, and posterior tibial pulses.

ANS: D The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

A patient with a comminuted fracture of the right femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and have the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. turn the patient partially to each side with the assistance of another nurse. d. have the patient lift the buttocks by bending and pushing with the left leg.

ANS: D The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.

The second day after admission with a fractured pelvis, a patient develops acute onset confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check pupil reaction to light. d. Assess the oxygen saturation.

ANS: D The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions also are appropriate but will be done after the nurse assesses gas exchange.

While completing an admission history for a 73-year-old man with osteoarthritis admitted for knee arthroplasty, the nurse asks about the patient's perception of the reason for admission. The nurse expects the patient to relate which response to this question? A Recent knee trauma B Debilitating joint pain C Repeated knee infections D Onset of "frozen" knee joint

B Debilitating joint pain The most common reason for knee arthroplasty is debilitating joint pain despite attempts to manage it with exercise and drug therapy. Recent knee trauma, repeated knee infections, and onset of "frozen" knee joint are not primary indicators for a knee arthroplasty.

A 57-year-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement, if made by the patient to the nurse, indicates understanding of the procedure? A. "The bone density in my heel will be measured." B. "This procedure will not cause any pain or discomfort." C. "I will not be exposed to any radiation during the procedure." D. "I will need to remove my hearing aids before the procedure."

B. "This procedure will not cause any pain or discomfort." Dual-energy x-ray absorptiometry (DXA) is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound (QUS) evaluates density, elasticity, and strength of bone using ultrasound of the calcaneus (heel). Magnetic resonance imaging would require removal of objects such as hearing aids that have metal parts.

Which information in a 67-year-old woman's health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system? a. The patient sprained her ankle at age 13. b. The patient's mother became shorter with aging. c. The patient takes ibuprofen (Advil) for occasional headaches. d. The patient's father died of complications of miliary tuberculosis.

B. A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient's current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.

During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? A. The presence of bowed legs B. A measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation

B. A measurable loss of height A gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative it is present. A wide gait is used to support balance and does not indicate osteoporosis.

A female patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in her right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which problem? A. Atrophy B. Ankylosis C. Crepitation D. Contracture

B. Ankylosis Ankylosis is stiffness or fixation of a joint, whereas contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a flabby appearance of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies movement.

Which action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the orthopedic clinic? a. Grade leg muscle strength for a patient with back pain. b. Obtain blood sample for uric acid from a patient with gout. c. Perform straight-leg-raise testing for a patient with sciatica. d. Check for knee joint crepitation before arthroscopic surgery.

B. Drawing blood specimens is a common skill performed by UAP in clinic settings. The other actions are assessments and require registered nurse (RN)-level judgment and critical thinking.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg

B. Localized pain and warmth 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, not generalized throughout the leg.

In reviewing bone remodeling, what should the nurse know about the involvement of bone cells? A. Osteoclasts add canaliculi. B. Osteoblasts deposit new bone. C. Osteocytes are mature bone cells. D. Osteons create a dense bone structure.

B. Osteoblasts deposit new bone. Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells, and osteons or Haversian systems create a dense bone structure, but these are not involved with bone remodeling.

The nurse formulates a nursing diagnosis of impaired physical mobility related to decreased muscle strength for a 78-year-old patient following left total knee replacement. What would be an appropriate nursing intervention for this patient? A Promote vitamin C and calcium intake in the diet. B Provide passive range of motion to all of the joints q4hr. C Encourage isometric quadriceps-setting exercises at least qid. D Keep the left leg in extension and abduction to prevent contractures.

C Encourage isometric quadriceps-setting exercises at least qid. Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery along with a continuous passive motion (CPM) machine. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to do active range of motion to all joints. Keeping the leg in one position (extension and abduction) potentially will result in contractures.

The nurse is caring for a patient with osteoarthritis who is about to undergo total left knee arthroplasty. The nurse assesses the patient carefully to be sure that there is no evidence of what in the preoperative period? A Pain B Left knee stiffness C Left knee infection D Left knee instability

C Left knee infection It is critical that the patient be free of infection before a total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring extensive surgery. For this reason, the nurse monitors the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability may be present with osteoarthritis.

The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement? A. "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus." B. "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed." C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." D. "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management."

C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." 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 paralytic ileus and 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.

A 54-year-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM before a bone scan. The nurse should plan to send the patient for the bone scan at what time? A. 9:30 PM B. 10:00 AM C. 11:00 AM D. 1:00 PM

C. 11:00 AM A technician usually administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 AM, the procedure should be done at 11:00 AM. 10:00 AM would be too early; 1:00 PM and 9:30 PM would be too late.

The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus? A. 22-year-old female with gonorrhea who is an IV drug user B. 48-year-old male with muscular dystrophy and acute bronchitis C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer D. 68-year-old female with hypertension who had a knee arthroplasty 3 years ago

C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices such as joint replacements. 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 determines that dietary teaching for a 75-year-old patient with osteoporosis has been successful when the patient selects which highest-calcium meal? A. Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk 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

A 63-year-old woman has been taking prednisone (Deltasone) daily for several years after a kidney transplant to prevent organ rejection. What is most important for the nurse to assess? A. Staggering gait B. Ruptured tendon C. Back or neck pain D. Tardive dyskinesia

C. Back or neck pain Osteoporosis with resultant fractures is a frequent and serious complication of systemic corticosteroid therapy. The ribs and vertebrae are affected the most, and patients should be observed for signs of compression fractures (back and neck pain). Phenytoin (Dilantin) is an antiseizure medication. An adverse effect of phenytoin is an ataxic (or staggering) gait. A rare adverse effect of ciprofloxacin (Cipro) and other fluoroquinolones is tendon rupture, usually of the Achilles tendon. The highest risk is in people age 60 and older and in people taking corticosteroids. Antipsychotics and antidepressants may cause tardive dyskinesia, which is characterized by involuntary movements of the tongue and face.

Which medication information will the nurse identify as a concern for a patient's musculoskeletal status? a. The patient takes a daily multivitamin and calcium supplement. b. The patient takes hormone therapy (HT) to prevent "hot flashes." c. The patient has severe asthma and requires frequent therapy with oral corticosteroids. d. The patient has migraine headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs).

C. Frequent or chronic corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.

The nurse prepares to administer IV ibandronate (Boniva) to a 67-year-old woman with osteoporosis. What is a priority laboratory assessment to make before the administration of ibandronate? A. Serum calcium B. Serum creatinine C. Serum phosphate D. Serum alkaline phosphatase

C. Serum phosphate Ibandronate is a bisphosphonate that is administered IV every 3 months and is administered slowly over 15 to 30 seconds to prevent renal damage. Ibandronate should not be used by patients taking other nephrotoxic drugs or by those with severe renal impairment (defined as serum creatinine above 2.3 mg/dL or creatinine clearance less than 30 mL/min).

The nurse is completing a neurovascular assessment on the patient with a tibial fracture and a cast. The feet are pulseless, pale, and cool. The patient says they are numb. What should the nurse suspect is occurring? A Paresthesia B Pitting edema C Poor venous return D Compartment syndrome

D Compartment syndrome The nurse should suspect compartment syndrome with one or more of the following six Ps: paresthesia, pallor, pulselessness, pain distal to the injury and unrelieved with opioids, pressure increases in the compartment, and paralysis. Although paresthesia and poor venous return are evident, these are just some of the manifestations of compartment syndrome.

This morning a 21-year-old male patient had a long leg cast applied and wants to get up and try out his crutches before dinner. The nurse will not allow this. What is the best rationale that the nurse should give the patient for this decision? A The cast is not dry yet, and it may be damaged while using crutches. B The nurse does not have anyone available to accompany the patient. C Rest, ice, compression, and elevation are in process to decrease pain. D Excess edema and other problems are prevented when the leg is elevated for 24 hours

D Excess edema and other problems are prevented when the leg is elevated for 24 hours For the first 24 hours after a lower extremity cast is applied, the leg will be elevated on pillows above the heart level to avoid excessive edema and compartment syndrome. The cast will also be drying during this 24-hour period. RICE is used for soft tissue injuries, not with long leg casts.

The nurse is caring for a 75-year-old woman who underwent left total knee arthroplasty and has a new order to be "up in chair today before noon." What action should the nurse take to protect the knee joint while carrying out the order? A Administer a dose of prescribed analgesic before completing the order. B Ask the physical therapist for a walker to limit weight bearing while getting out of bed. C Keep the continuous passive motion machine in place while lifting the patient from bed to chair. D Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting.

D Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting. The nurse should apply a knee immobilizer for stability before assisting the patient to get out of bed. This is a standard measure to protect the knee during movement following surgery. Although an analgesic should be given before the patient gets up in the chair for the first time, it will not protect the knee joint. Full weight bearing is begun before discharge, so a walker will not be used if the patient did not need one before the surgery. The CPM machine is not kept in place while the patient is getting up to the chair.

The nurse is completing discharge teaching with an 80-year-old male patient who underwent right total hip arthroplasty. The nurse identifies a need for further instruction if the patient states the need to A avoid crossing his legs. B use a toilet elevator on toilet seat. C notify future caregivers about the prosthesis. D maintain hip in adduction and internal rotation.

D maintain hip in adduction and internal rotation. The patient should not force hip into adduction or force hip into internal rotation as these movements could displace the hip replacement. Avoiding crossing the legs, using a toilet elevator on a toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? A. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. B. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. C. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements and/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 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? A. Ambulate the patient to the bathroom every 2 hours. B. Ask the patient about preferred activities to relieve boredom. C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. D. Perform frequent position changes and range-of-motion exercises.

D. Perform frequent position changes and range-of-motion exercises. The patient is at risk for atelectasis of the lungs and for 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 (ROM) 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, and dangling the legs every 2 to 4 hours may be too painful. The priority is position changes and ROM exercises.

The nurse who notes that a 59-year-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about a. discography studies. b. myelographic testing. c. magnetic resonance imaging (MRI). d. dual-energy x-ray absorptiometry (DXA).

D. The decreased height and the patient's age suggest that the patient may have osteoporosis and that bone density testing is needed. Discography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic tests for osteoporosis.

A 54-year-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information? A. Two additional follow-up scans will be required. B. There will be only mild pain associated with the procedure. C. The procedure takes approximately 15 to 30 minutes to complete. D. The patient will be asked to drink increased fluids after the procedure.

D. The patient will be asked to drink increased fluids after the procedure. Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans and no pain are associated with bone scans that take 1 hour of lying supine.

A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) a."The beads are used to directly deliver antibiotics to the site of the infection." b."There are no effective oral or IV antibiotics to treat most cases of bone infection." c."This is the safest method of delivering long-term antibiotic therapy for a bone infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." e."The ischemia and bone death that occur with osteomyelitis are impenetrable to IV antibiotics."

a."The beads are used to directly deliver antibiotics to the site of the infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of IV and oral antibiotics. Antibiotic-impregnated polymethylmethacrylate bead chains may be implanted during surgery to aid in combating the infection.

In caring for a patient after a spinal fusion, the nurse would immediately report to the physician which patient symptom? a.The patient experiences a single episode of emesis. b.The patient is unable to move the lower extremities. c. The patient is nauseated and has not voided in 4 hours. d. The patient complains of pain at the bone graft donor site.

b.The patient is unable to move the lower extremities. After spinal fusion surgery, the nurse should frequently monitor peripheral neurologic signs. Movement of the arms and legs and assessment of sensation should be unchanged in comparison with the preoperative status. These assessments are usually repeated every 2 to 4 hours during the first 48 hours after surgery, and findings are compared with those of the preoperative assessment. Paresthesias, such as numbness and tingling sensation, may not be relieved immediately after surgery. The nurse should document any new muscle weakness or paresthesias and report this to the surgeon immediately.

While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as a.hypertension. b.thyroid problems. c.diabetes mellitus. d.chronic bronchitis.

c.diabetes mellitus The nurse should question the patient about past medical problems because certain illnesses are known to affect the musculoskeletal system directly or indirectly. These diseases include tuberculosis, poliomyelitis, diabetes mellitus, parathyroid problems, hemophilia, rickets, soft tissue infection, and neuromuscular disabilities.

The bone cells that function in the resorption of bone tissue are called a.osteoids b.osteocytes c.osteoclasts d.osteoblasts

c.osteoclasts Osteoclasts participate in bone remodeling by assisting in the breakdown of bone tissue.