Chapter 53: Care of Patients with Musculoskeletal Problems Nursing School Test Banks

Chapter 53: Care of Patients with Musculoskeletal Problems

Test Bank

MULTIPLE CHOICE

1. The RN has assigned a client with 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 range of motion (ROM) to all weight-bearing joints.

b.

Position the client upright to promote lung expansion.

c.

Place a pillow between the clients knees when 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, but active weight-bearing exercise reduces bone resorption and is a better choice if possible. Positioning the client to promote lung expansion and positioning with a pillow for side-lying are important interventions for any client. The most important intervention for this client is to prevent bone fractures.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

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 fracture when they fall. Clutter in the room is a risk factor for falls. The other choices have nothing to do with prevention of bone fracture in a client with primary osteoporosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

3. Which instruction does 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Teaching/Learning

4. After the administration of each dose of zoledronic acid (Zometa), it is most important for the nurse to determine which finding?

a.

Capillary refill

b.

Pain relief

c.

Level of consciousness

d.

Urine output

ANS: D

Zoledronic acid is a bisphosphonate that helps protect bones and prevent fractures. Urine output and serum creatinine should be monitored because this drug can be toxic to the kidneys. Zometa does not relieve pain or affect capillary refill or level of consciousness.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiologic Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Assessment)

5. Which nursing intervention is most effective in preventing 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

6. While caring for a client who has chronic osteomyelitis and wound drainage, which intervention is most important for the nurse to implement?

a.

Cover the wound with a dressing.

b.

Teach about the cause of the infection.

c.

Monitor the erythrocyte sedimentation rate (ESR).

d.

Prepare the client for hyperbaric oxygenation.

ANS: A

If an open wound is present in the hospital or long-term care setting, the clients treatment usually includes Standard Precautions for limiting infection by covering the wound. Teaching about the cause of the infection could prevent further episodes of infection, but does not take care of the current problem. The ESR just tells the health care provider that an inflammatory process is going on. Hyperbaric oxygenation is used only for clients with chronic, unremitting osteomyelitis. Covering the wound would be the most important step for the nurse to take first.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlHandling Hazardous and Infectious Materials)

MSC: Integrated Process: Nursing Process (Implementation)

7. Which exercise does 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 proved to reduce or slow bone loss without causing vertebral compression. High-impact aerobics, jogging, and bowling are activities that actually could cause fracture in a client with osteoporosis. Walking would be the best choice as an exercise.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC: Integrated Process: Teaching/Learning

8. An adult clients susceptibility to osteoporosis is caused by which aspect of his or her history?

a.

Fractured arm at age 16

b.

Active 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 low-trauma 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.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 53-1, p. 1120

TOP: Client Needs Category: Health Promotion and Maintenance (Lifestyle Choices)

MSC: Integrated Process: Nursing Process (Analysis)

9. Which client does the nurse assess more carefully for risk of developing primary osteoporosis?

a.

African-American client

b.

Resident of a nursing home

c.

Client who eats meat with every meal

d.

Client who drinks 6 cups of coffee daily

ANS: D

Excessive consumption of caffeine and alcohol has been shown to be a risk factor for primary osteoporosis because of loss of calcium in the urine. Being white or Asian has been identified as causing a higher risk for developing osteoporosis at an earlier age compared with African-American ethnicity. Being a resident of a nursing home who is not exposed to sunlight could be a risk factor, but just being a resident does not predispose to osteoporosis. Meat is high in protein. Protein deficiency has been identified as a risk factor.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC: Integrated Process: Nursing Process (Analysis)

10. A clients susceptibility to osteomalacia is related to which risk factor?

a.

Calcium level of 11 mg/dL

b.

Diet high in milk and soy

c.

Phosphate level of 1.0 mg/dL

d.

Taking vitamin D supplements

ANS: C

A low serum phosphate level predisposes a client to osteomalacia. The normal range is 2.5 to 4.5 mg/dL. Vitamin D supplements, diets high in vitamin D (e.g., milk and soy), and high calcium levels are not risk factors for osteomalacia.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1127

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Analysis)

11. A female client who is a carrier of the gene for Duchennes muscular dystrophy asks whether any of her daughters will have this disease. Which is the nurses best response?

a.

Both parents must have the defective gene.

b.

Your daughter cannot get the disease.

c.

Your daughters have a 50% chance of developing the disease.

d.

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 then are carriers, and to their sons, who then have the disease. This type of muscular dystrophy affects only males. The other responses are not accurate.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1140

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Planning)

12. When preparing to care for a client with a family history of Pagets 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

Pagets 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, but exercise may be difficult because of pain and danger of fracture. The diet should be rich in calcium and vitamin D.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC: Integrated Process: Nursing Process (Planning)

13. The mother of a 16-year-old client diagnosed with Ewings sarcoma expresses concern that her son seems to be angry at everyone in the family. How does 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 loss of control over their lives when a diagnosis of cancer (e.g., Ewings 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 return to normal when he goes home.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Family Dynamics)

MSC: Integrated Process: Nursing Process (Analysis)

14. A client diagnosed with primary bone sarcoma of the leg is scheduled for tumor removal. The client expresses fear of loss of function. Which is the nurses 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 is necessary to save your life.

ANS: A

The client with bone cancer is expected to adjust to actual or impending loss with help. An expected outcome of nursing care includes the ability of the client to verbalize the reality of the loss and seek social support. The other responses do not reflect therapeutic communication techniques.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Nursing Process (Implementation)

15. A client newly diagnosed with Ewings sarcoma is most likely to exhibit which laboratory finding?

a.

Elevated red blood cells (RBCs)

b.

Elevated alkaline phosphatase (ALP)

c.

Decreased erythrocyte sedimentation rate (ESR)

d.

Decreased serum lactate dehydrogenase (LDH)

ANS: B

In Ewings sarcoma, laboratory results typically would demonstrate elevated alkaline phosphatase because of higher osteoblastic activity. Red blood cells would be low indicating anemia, the ESR would be elevated owing to tissue inflammation, and the LDH would be elevated as the cancer progresses.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1135

TOP: Client Needs Category: Physiologic Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Assessment)

16. A client is prescribed alendronate (Fosamax). Which statement indicates that the client understands teaching about this drug?

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 as calcium.

ANS: A

Fosamax needs to be taken on an empty stomach with a full glass of water for best absorption and to prevent esophagitis. After taking the drug, the client needs to stay upright for 30 minutes. Calcium can be taken, but not at the same time as Fosamax.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Teaching/Learning

17. A client is seen at the clinic with the medical diagnosis of osteomalacia. When taking the clients history, what does the nurse assess for?

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 described. However, the most significant risk factor in this disease process is vitamin D deficiency.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

18. The nurse has educated a client on Pagets disease. Which statement by the client indicates good understanding of causative factors?

a.

It is caused by lack of calcium in my diet.

b.

I probably had a fracture that caused it.

c.

This disease occurs because of lack of exercise.

d.

I may have a genetic predisposition.

ANS: D

Pagets disease has been noted in up to 30% of people with a positive family history. The other responses are not accurate as a cause of Pagets disease.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Evaluation)

19. A client has severe Pagets disease. Which factor has the highest priority when the nurse intervenes in the care of this client?

a.

Dietary education

b.

Exercise program

c.

Genetic testing

d.

Relief of pain

ANS: D

The primary intervention for Pagets disease is drug therapy with pain management as a priority. This can be accomplished with various drugs and complementary measures. All the other options are treatments for Pagets disease. Pain management is the priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

20. 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.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1132

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

21. When providing care for a client who has had a dbridement for osteomyelitis, which intervention is most important for the nurse to implement?

a.

Assess the white blood cell count.

b.

Assess circulation in the distal extremities.

c.

Administer pain medication.

d.

Monitor temperature.

ANS: B

All the interventions would be completed during 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

22. A client who has been diagnosed with osteomyelitis is beginning antibiotic therapy. Which information does the nurse include in the clients teaching plan?

a.

Needing a consultation with a surgeon

b.

Continuing on Contact Isolation at home

c.

Remaining in the hospital for the rest of the treatment

d.

Receiving antibiotic treatment at home from the home health nurse

ANS: D

Typically, osteomyelitis requires treatment with IV antibiotics for several weeks. The client will leave the hospital with a central IV catheter (PICC) for home infusion of the medication. Oral antibiotics usually follow the IV regimen for several more weeks. Surgical intervention is reserved for clients with chronic osteomyelitis if medication therapy is ineffective. Contact Isolation is needed only if the infection can be transmitted to another person when copious drainage is present.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

23. Two hours after limb salvage surgery for a client with left leg bone sarcoma, the nurse notes that the toes of the left foot are more edematous, are cooler to the touch, and have a slower capillary refill. Which action does the nurse take first?

a.

Apply ice to the distal extremity.

b.

Check the splint for proper placement.

c.

Elevate the left foot.

d.

Loosen the pressure dressing.

ANS: B

Assessment of the neurovascular status of the affected extremity should be performed every 1 to 2 hours after surgery. Splinting or casting the limb may cause neurovascular compromise and needs to be checked for proper placement. Applying ice will cause vasoconstriction, which will further impair blood flow. Elevation of the foot will similarly decrease circulation to the area.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationUnexpected Response to Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

24. The nurse is caring for a client with a lesion in the area of the tibia that is swollen and tender. Which client problem is the highest priority for nursing care?

a.

Need for increased calories related to increased metabolism

b.

Pain management related to physical injury

c.

Compromised self-care related to weakness

d.

Safety risk related to skeletal impairment

ANS: B

A palpable mass and swelling in the area of the tibia are symptoms of osteochondroma, which is a common, benign bone tumor. Pain is the most common manifestation of a benign bone tumor. The other distractors are important, but pain management is the highest priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiologic AdaptationIllness Management)

MSC: Integrated Process: Nursing Process (Planning)

25. Which client is at highest risk for the development of plantar fasciitis?

a.

Young adult runner

b.

Adolescent swimmer

c.

Older adult client who walks with a cane

d.

Adult client confined to a wheelchair

ANS: A

Plantar fasciitis accounts for 10% of running-related injuries. Obesity is also thought to be a factor in the development of plantar fasciitis. It is often seen in middle-aged and older adults who are ambulatory, but plantar fasciitis is most common in athletes, especially runners.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1139

TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC: Integrated Process: Nursing Process (Analysis)

26. The nurse is caring for a client with rheumatoid arthritis. For which condition does the nurse assess most carefully?

a.

Dupuytrens contracture

b.

Hallux valgus

c.

Mortons neuroma

d.

Plantar fasciitis

ANS: B

Hallux valgus deformity is a common foot problem in which the great toe deviates laterally at the first metatarsophalangeal joint. This condition often occurs as a result of poorly fitted shoes, family history, osteoarthritis, and rheumatoid arthritis. The other responses are not applicable to rheumatoid arthritis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

27. The nurse is assessing a client with Pagets disease. Which assessment finding leads the nurse to notify the health care provider immediately?

a.

Client is 5 feet in height and weighs 130 pounds.

b.

Long bones of the legs and arms are bowing.

c.

Base of the skull is enlarged with changes in vital signs.

d.

Mild pain is present in the area of the hips and pelvis.

ANS: C

It is common for the client with Pagets disease to be short in stature and to develop bowing of the long bones and mild to moderate pain, which often occurs in weight-bearing joints. When the skull becomes enlarged with basilar invagination, the brainstem may become damaged; this can threaten the vital sign center and life itself.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

MULTIPLE RESPONSE

1. The nurse reviews the health history of a client with acute osteomyelitis. Which findings might have contributed to the diagnosis? (Select all that apply.)

a.

Recent dental work

b.

Urinary tract infection

c.

Pregnancy

d.

Age

e.

Hemodialysis

f.

Gastrointestinal infection

ANS: B, E, F

Poor dental hygiene and gum infection (not necessarily recent dental work), urinary tract infection, hemodialysis, and Salmonella infection of the gastrointestinal tract can be sources of infection and, consequently, osteomyelitis. Pregnancy and advancing age are not necessarily precursors to osteomyelitis, even though urinary tract infection leading to osteomyelitis is common in older men.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1131

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

2. 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.

Client is a white woman with a body mass index (BMI) of 19.4.

b.

Client fractured her wrist badly in a fall last year.

c.

Client drinks at least four cans of diet cola every day.

d.

Client does tai chi exercises for 45 minutes every morning.

e.

Client has smoked two packs of cigarettes a day for 40 years.

f.

Client has taken estrogen (Premarin) 0.625 mg daily since menopause.

ANS: A, B, C, E

Risk factors for osteoporosis include white race, female gender, small body frame, large intake of caffeinated carbonated drinks, and smoking cigarettes. Recent fracture after a fall indicates that the clients bones may be soft and/or thin. Hormone replacement therapy, late onset of menopause, and regular exercise help reduce the risk of osteoporosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

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