Musculoskeletal - Student Review Questions Answers - Week 8

Ignatavicius: Medical-Surgical Nursing, 6th Edition Chapter 52: Assessment of the Musculoskeletal System Student Review Question Answers: MULTIPLE CHOICE 1. Which of the postoperative orders will the nurse clarify with the surgeon before discharging the client who just had arthroscopic surgery on the right knee? a. Keep right leg elevated on a soft pillow b. Non–weight-bearing by right leg for 48 hours c. Bathroom privileges with assistance and crutches d. Two tablets of propoxyphene-acetaminophen (Darvocet N-100) every 4 hours for pain ANS: D Each tablet of Darvocet N-100 contains 650 mg of acetaminophen, so each dose = 1300 mg of acetaminophen. 1300 mg every 4 hours = 7800 mg of acetaminophen, well over the 4000-mg safe maximal dose for 24 hours. The rest of the orders are appropriate. 2. The client tells the nurse that his arm cast feels really tight and his fingers are puffy. What is the nurse’s best response? a. “Elevate your arm on two pillows and apply ice to the cast.” b. “Continue to take ibuprofen (Motrin) until the swelling subsides.” c. “It is normal for a new cast to feel a little tight for the first few days.” d. “Please come to clinic today to have your arm checked by the physician.” ANS: D Puffy fingers and feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the physician, because delay of treatment can cause permanent damage to the extremity. 3. The client who had a long leg cast applied last week tells the nurse that he just can’t seem to catch his breath and feels a bit lightheaded. Which is the priority action of the nurse? a. Listening to the client’s lungs and checking the client’s blood glucose level b. Giving the client 2 L of oxygen via nasal cannula and checking vital signs c. Check the client’s pulse oximetry and arranging emergency transfer to the hospital d. Reassuring the client that it takes much more effort to move with a long leg cast ANS: C The client’s symptoms are consistent with the development of pulmonary embolism (PE) caused by leg immobility in the long cast. The nurse should check the client’s pulse oximetry reading and arrange for transfer to the hospital for further testing and treatment. The client should not be reassured that the symptoms are caused by exertion. The nurse can check vital signs, administer oxygen, and check the client’s blood glucose level while waiting for transport to the emergency department. 4. Which action by the client with left-sided weakness indicates that additional teaching is needed about proper cane use? a. The client holds the cane in his right hand. b. The client advances the cane while his right leg moves forward. c. The client steps forward first with his right leg when ambulating. d. The client’s elbow is flexed 15 to 20 degrees when holding the cane. ANS: B The cane should be held on the strong right side so that it provides support for the weaker left side. The cane should be advanced with the opposite affected lower limb (the left leg for this client). The client should step forward with the strong right leg when ambulating. The elbow should be flexed 15 to 20 degrees when holding the cane. 5. Which assessment finding will the nurse share with the occupational therapist for further assessment and treatment of the client with rheumatoid arthritis? a. The client has difficulty sleeping because of pain in the knees and elbows. b. The client has difficulty tying shoelaces and doing zippers on clothing. c. The client’s knees are swollen with crepitus and have limited range of motion. d. The client has generalized joint stiffness that is worse in the early morning. ANS: B The functional assessment helps nurses and therapists measure how functional the client is with activities of daily living, including dressing. The occupational therapist can assist the client to explore clothing options that are easier to manage with arthritic fingers. 6. The nurse is caring for a client who is to have a computed tomography (CT) scan of the leg. Which assessment question will the nurse ask the client prior to the procedure? a. “Do you have any metal clips, plates, or pins in your body?” b. “Have you had anything to eat or drink in the last 6 hours?” c. “Do you have someone to drive you home after the procedure?” d. “Do you have any allergies to shrimp, scallops, or other seafood?” ANS: D IV contrast that contains iodine may be required for CT scans to rule out malignancy. The client should be assessed for allergy to shellfish, which contain high amounts of iodine. The other questions are not relevant when a CT scan is to be obtained. 7. The nurse is assessing a client who complains of severe knee pain after a fall. Which question will the nurse ask to determine the radiation of the pain? a. “What makes the pain better or worse?” b. “Are you able to bear any weight on the knee at all?” c. “Does the pain move to another area from your knee?” d. “How would you rate the pain on a scale of 1 to 10?” ANS: C To determine radiation of the pain, the nurse asks the client if the pain moves to another area from the knee. The other questions address the amount, functional impact, and alleviating or aggravating factors of the pain. 8. The nurse is caring for an older adult client who has had leg amputation surgery the previous day. During the admission assessment, the client tells the nurse, “I don’t want to live with only one leg, so I should have died during the surgery.” Which is the nurse’s best response? a. “Your vital signs are good, and you are doing just fine right now.” b. “Your children are waiting outside and do not want to lose their parent.” c. “Remember that you are still the same person inside, with a missing body part.” d. “You will be able to do some of the same things as before you became disabled.” ANS: B The client feels like less of a person following the amputation, so the nurse should remind the client that he is still the same person inside. The nurse should not try to make the client feel guilty by saying that his children do not want to lose their parent. The nurse should not ignore the client’s feelings by focusing on vital signs. The nurse should not refer to the client as being “disabled.” 9. Which instruction will the nurse give to the client before he or she has electromyography (EMG)? a. “Make sure that you have someone to drive you home after the test.” b. “Do not eat or drink anything for at least 6 hours before the test.” c. “You will have to avoid heavy lifting for 24 hours following the test.” d. “Do not take your cyclobenzaprine (Flexeril) for the 2 days before the test.” ANS: D Electromyography (EMG) testing measures nerve signal transmission to and through muscles. Skeletal muscle relaxants such as Flexeril can affect test results and should be avoided for at least 2 days prior to the test. The other instructions are not relevant prior to EMG testing. 10. The nurse is caring for a client with prostate cancer. Which laboratory finding indicates to the nurse that the cancer has metastasized to the bone? a. Serum calcium, 21.6 mg/dL b. Creatine kinase, 45 U/mL c. Alkaline phosphatase, 45 IU/mL d. Lactate dehydrogenase, 66 U/L ANS: A Metastasis of tumor to bone results in release of calcium into the bloodstream, causing an elevation of the serum calcium level (normal range, 9 to 10.5 mg/dL). The other laboratory values are within normal limits and do not indicate metastasis to the bone. 11. The nurse is caring for a client who presents with achy jaw pain. Which assessment technique will the nurse use to determine if the client has inflammation of the temporomandibular joint (TMJ)? a. The nurse checks for decayed, fractured, loose, or missing teeth. b. The nurse observes the jaw joint as the client chews a piece of food. c. The nurse palpates the joint during movement for tenderness or crepitus. d. The nurse observes for asymmetrical joint protrusion when the client’s mouth is closed. ANS: A The temporomandibular joints are best assessed by palpation while the client opens his or her mouth. The other assessment techniques are not effective for assessing possible TMJ inflammation. 12. The nurse is caring for a client who is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms. Which condition does the nurse suspect based on these assessment findings? a. The client has a dislocated shoulder. b. The client has a lesion in the rotator cuff. c. The client has osteoarthritis of the shoulder. d. The client has atrophy of the supraspinatus muscle. ANS: B Rotator cuff lesions may cause limited range of motion and pain and muscle spasm during abduction, whereas forward flexion stays fairly normal. The assessment findings are not consistent with the other conditions. MULTIPLE RESPONSE 1. The nurse is performing a medical history and physical assessment for a client. Which assessment findings lead the nurse to conclude that the client is at risk for development of osteoporosis? (Select all that apply.) a. The client is a white woman with a body mass index (BMI) of 19.4. b. The client fractured her wrist badly in a fall last year. c. The client drinks at least four cans of diet cola every day. d. The client does tai chi exercises for 45 minutes every morning. e. The client has smoked two packs of cigarettes a day for 40 years. f. The client takes prednisone, 15 mg daily, for long-standing COPD. g. The client has taken estrogen (Premarin), 0.625 mg, daily since menopause at age 54. ANS: A, B, C, E, F Risk factors for osteoporosis include white race, female gender, small body frame, large intake of caffeinated carbonated drinks, smoking cigarettes, and long-term use of corticosteroids. Recent fracture after a fall indicates that the client’s bones may be soft and/or thin. Hormone replacement therapy, late onset of menopause, and regular exercise help reduce the risk of osteoporosis. Chapter 53: Care of Patients with Musculoskeletal Problems MULTIPLE CHOICE 1. The RN assigned a client who has severe osteoporosis to an LPN. Which information about the care of the client is most important for the RN to provide the LPN? a. Provide passive ROM to all weight-bearing joints. b. Position the client upright to promote lung expansion. c. Place a pillow between the client’s knees when he or she is in the side-lying position. d. Use a lift sheet to reposition the client. ANS: D Severe osteoporosis causes such bone density loss that pathologic fractures can easily occur when lifting or pulling a client. Use of a lift sheet when positioning reduces this risk. Passive range of motion prevents contractures. Weight-bearing exercise reduces bone resorption. Positioning the client to promote lung expansion and positioning with a pillow are important for any client. The most important intervention for this client is to prevent bone fractures. 2. Which instruction is most important for the RN to provide to the nursing assistant assigned to care for a client with primary osteoporosis? a. “Clean up clutter in the room.” b. “Encourage the client to bathe herself or himself." c. “Monitor urinary output.” d. “Perform passive range-of-motion exercises.” ANS: A Clients with osteoporosis are at risk for fractures when they fall. Clutter in the room is a risk factor for falls. The other distractors have nothing to do with the prevention of bone fractures in a client with primary osteoporosis. 3. Which instruction will the nurse include in the discharge teaching plan of a client who has osteoporosis? a. “Avoid using scatter rugs.” b. “Avoid weight-bearing exercises.” c. “Use a cane when walking outside.” d. “Reduce the amount of protein in your diet.” ANS: A To avoid falls, the client should keep a hazard-free environment, including avoiding scatter rugs, cluttered rooms, and wet floor areas. Weight-bearing exercises help prevent bone resorption. A cane is not needed unless the client has a physical disability. A protein deficiency should be avoided because it might cause a reduction in bone density. 4. A client is being discharged from the hospital with the diagnosis of osteoporosis and hip fracture. When planning this client’s discharge, it is most important for the nurse to coordinate with which member of the health care team? a. Case manager b. Osteoporosis Foundation representative c. Occupational therapist d. Wound care nurse ANS: A The client with osteoporosis with a fracture may need to be transferred to a long-term care facility for rehabilitation or permanent residence. Case managers assist in preparing the client and family for placement. An Osteoporosis Foundation representative can provide information regarding the disease, but is not the most important member of the health care team at this time. An occupational therapist and wound care nurse are important members of the health care team, but are not vital in the situation described in this question. 5. After the administration of each dose of zoledronic acid (Zometa), it is most important for the nurse to determine which finding? a. Heart rate b. Pain relief c. Tumor size d. Urine output ANS: D Zoledronic acid is a bisphosphonate that helps protect bones and prevent fractures. Urine output should be monitored because this drug can be toxic to the kidneys. Zometa does not relieve pain or affect heart rate. Tumor size cannot be measured in a nursing assessment. Zoledronic acid does not affect tumor size. 6. Which nursing intervention is most effective in preventing the transfer of an organism from the wound of a client with osteomyelitis to other clients? a. Contact precautions b. Restriction of visitors c. Irrigating the wound as needed d. Leaving the wound open to air ANS: A In the presence of wound drainage, contact precautions may be used to prevent the spread of the offending organism to other clients and health care personnel. Restricting visitors does not prevent transfer. One visitor could possibly transfer the bacteria to another surface. Irrigating the wound would not destroy the organism. The wound should be covered to prevent transfer of the organism. 7. While caring for a client who has chronic osteomyelitis and wound drainage, which intervention is most important for the nurse to implement? a. Covering the wound with a dressing b. Teaching about the cause of the infection c. Monitoring the erythrocyte sedimentation rate (ESR) d. Preparing the client for hyperbaric oxygenation ANS: A If an open wound is present in the hospital or long-term care setting, the client’s treatment usually includes standard precautions for limiting infection by covering the wound. Teaching about the cause of the infection could prevent further episodes of the infection, but does not take care of the current problem. The ESR rate just tells the health care provider that an inflammatory process is going on. Hyperbaric oxygenation is only used for clients with chronic, unremitting osteomyelitis. Covering the wound would be the most important step for the nurse to take first. 8. Which exercise will the nurse recommend to a client at risk for osteoporosis? a. High-impact aerobics 45 minutes once weekly b. Walking 30 minutes three times weekly c. Jogging 30 minutes four times weekly d. Bowling for 1 hour twice weekly ANS: B Weight-bearing, nonjarring exercises have been proven to reduce or slow bone loss without causing vertebral compression. High-impact aerobics, jogging, and bowling are activities that actually could cause fractures in a client with osteoporosis. 9. An adult client’s susceptibility to osteoporosis is caused by which aspect in their history? a. Fractured arm b. Smoking c. Vitamin D supplements d. Weight lifting ANS: B A history of smoking has been identified as a risk factor for osteoporosis. A history of lowtrauma fracture after the age of 50 has been identified as a risk factor. Vitamin D and weight lifting are measures that can be used to prevent this disease. 10. A client’s susceptibility to primary osteoporosis is related to what factor? a. African-American ethnicity b. Resident of a nursing home c. Eating meat with every meal d. Taking oral contraceptives ANS: D Certain medications, such as corticosteroids, increase the risk of osteoporosis. Being white or Asian has been identified as a risk factor. A resident of a nursing home who is not exposed to sunlight could be a risk factor; just being a resident does not predispose to osteoporosis. Meat is high in protein. Protein deficiency has been identified as a risk factor. 11. A client’s susceptibility to osteomalacia is related to which risk factor? a. Calcium level of 11 mg/dL (normal = 8.2 – 10.2 mg/dL) b. Diet high in milk and soy c. Phosphate level of 1.0 mg/dL (normal = 2.5 – 4.5 mg/dL) d. Taking vitamin D supplements ANS: C A low serum phosphate level predisposes a client to osteomalacia. Vitamin D, diets high in vitamin D (e.g., milk and soy), and high calcium levels are not risk factors for osteomalacia. 12. A female client who is a carrier of the gene for Duchenne’s muscular dystrophy asks if any of her daughters will have this disease. Which is the nurse’s best response? a. b. c. d. “Both parents must have the defective gene.” “Your daughter cannot get the disease.” “Your daughters have a 50% chance of developing the disease.” “Your daughters will become carriers of the gene.” ANS: B Women who are carriers have a 50% chance of passing the gene to their daughter, who are then carriers and their sons, who then have the disease. This type of muscular dystrophy affects only males. 13. When preparing to care for a client with a family history of Paget’s disease, it is most important for the nurse to include education in which area? a. Avoidance of infections b. Exercise program c. Nutrition high in vitamin C d. Need for genetic testing ANS: D Paget’s disease has been noted in up to 30% of people with a positive family history. Clients who have a history of this disease in their family should be taught the importance of genetic counseling. An exercise program may be started with the help of a physical therapist. Exercise may be difficult because of pain and danger of fracture. The diet should be rich in calcium and vitamin C. 14. The mother of a 16-year-old client diagnosed with Ewing’s sarcoma expresses concern that her son seems to be angry at everyone in the family. How will the nurse respond? a. “You need to set limits with your son.” b. “This is a normal stage in the grieving process.” c. “He will be back to normal when he leaves the hospital.” d. “This is typical behavior for a teenager.” ANS: B Clients often experience a loss of control over their lives when a diagnosis of cancer (e.g., Ewing’s sarcoma) is made. Clients may progress through the grieving process, which includes denial, followed by anger. Setting limits without understanding the grieving process can make the client feel that he has no control. The behavior is not typical of a teenager without the disease. It is part of the grieving process. The mother should not expect the son to go back to “normal” when he goes home. 15. Assessment findings reveal that a client with Ewing’s sarcoma is afraid of dying. Which health care team member is likely to be most helpful in planning this client’s care? a. Clergy member b. Home health care nurse c. Physician d. Social worker ANS: A Although all these health care team members can assist in the care of this client, counselors, members of the clergy, or spiritual leaders may provide additional assistance in promoting acceptance of possible impending death. 16. A client diagnosed with primary bone sarcoma of the leg is scheduled for tumor removal. He expresses fear of the loss of function. Which is the nurse’s best response? a. “It is normal to feel this way.” b. “Physical therapy will assist you to regain function.” c. “This surgery is better than an amputation.” d. “This surgery was necessary to save your life.” ANS: A The client with bone cancer is expected to adjust to actual or impending loss. An expected outcome of nursing care includes the ability of the client to verbalize the reality of the loss and seek social support. 17. A client newly diagnosed with fibrosarcoma is most likely to exhibit which behavior? a. Acceptance b. Bargaining c. Denial d. Resolution ANS: C A client with bone cancer is expected to adjust to actual or impending loss. Indicators include that the client will have the ability to progress through the stages of grief. The first stage of this process is denial that he has the disease. 18. Which statement indicates that the client understands teaching about alendronate (Fosamax)? a. “I should take this drug with a full glass of water.” b. “I need to lie down for 30 minutes after taking it.” c. “This drug should be taken after a meal.” d. “This drug needs to be taken at the same time with calcium.” ANS: A Fosamax needs to be taken on an empty stomach with a full glass of water. After taking the drug, the client needs to stay upright for 30 minutes. Fosamax should be taken on an empty stomach for best absorption. Calcium can be taken, but not at the same time as the Fosamax. 19. A female client is seen at the clinic with the medical diagnosis of osteomalacia. When taking the client’s history, what information is the most significant? a. Arm and leg strength b. Dietary intake of vitamin D c. Dietary intake of calcium d. Exercise habits ANS: B Vitamin D deficiency is the most important factor in the development of osteomalacia. Weak arm and leg strength may be seen, calcium deficiency plays a part in the disease process, and discomfort while exercising may be seen. However, the most significant risk factor in this disease process is vitamin D deficiency. 20. The client asks the nurse how she acquired Paget’s disease. Which is the best response by the nurse? a. “It is because of the lack of calcium in your diet.” b. “It was probably caused by a fracture.” c. “This disease occurs when there is a lack of exercise.” d. “You may have a genetic predisposition.” ANS: D Paget’s disease has been noted in up to 30% of people with a positive family history. 21. Which of the following has the highest priority when the nurse intervenes in the care of the client with severe Paget’s disease? a. Dietary education b. Exercise program c. Genetic testing d. Relief of pain ANS: D The primary intervention for Paget’s disease is drug therapy. Pain management is a priority and can be accomplished with various drugs and complementary measures. All the other distractors are treatments for Paget’s disease. Pain management is the priority. 22. Which assessment finding relates most directly to a diagnosis of chronic osteomyelitis? a. Erythema of the affected area b. Swelling around the affected area c. Temperature higher than 101° F (38° C) d. Ulceration of the skin ANS: D Fever, swelling, and erythema are far less common in chronic osteomyelitis, whereas ulceration, sinus tract formation, and localized pain are more characteristic. 23. When providing care for a client who has had a débridement for osteomyelitis, which intervention is most important for the nurse to implement? a. Assessing the white blood cell count b. Assessing circulation in the distal extremities c. Administering pain medication d. Monitoring temperature ANS: B All the interventions would be done during the care of this client. However, after resection of infected bone, neurovascular assessments must be done frequently because the client experiences increased swelling, which could cause neurovascular compromise.