The home care nurse visits an 84-yr-old woman with pneumonia after her discharge from
the hospital. Which age-related change in the musculoskeletal system should the nurse
expect? Muscle strength is scale grade 3/5
Rationale:
Decreased muscle strength is an age-related change of the musculoskeletal system caused by
decreased number and size of the muscle cells. The other assessment findings indicate
musculoskeletal abnormalities. A positive straight-leg-raising test indicates nerve root irritation from
intervertebral disk prolapse and herniation. An ulnar deviation or drift indicates rheumatoid arthritis
due to tendon contracture. Scoliosis is a lateral curvature of the spine.
The nurse is performing a musculoskeletal assessment on an 81-yr-old patient whose mobility
has been progressively declining. How should the nurse safely assess range of motion (ROM)
in the affected leg?
Observe the patient’s unassisted ROM in the affected leg.
Rationale:
Observing the patient’s active ROM is more accurate and safer than lifting weights. Passive ROM
should be performed with extreme caution; it may cause harm when performed on older patients.
A patient is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement by
the patient indicates understanding of the procedure? “This procedure will not cause any pain
or discomfort.”
Rationale:
DXA is painless and measures the bone mass of spine, femur, forearm, and total body with minimal
radiation exposure. A quantitative ultrasound evaluates bone density using ultrasound of the
calcaneus (heel). MRI would require removal of objects such as hearing aids that have metal parts.
A female patient with a history of rheumatoid arthritis complains of stiffness in her right knee and
complete fixation of the joint. What problem does the nurse anticipate will be identified in the patient's
history and physical examination?
Ankylosis
Rationale:
Ankylosis is stiffness or fixation of a joint. Contracture is reduced movement as a consequence of
fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a wasting of muscle leading to
decreased function and tone. Crepitation is a grating or crackling sound that accompanies joint
movement. Problem identification leads to determination of an appropriate treatment.
A 50-yr-old patient reports shoulder discomfort after raking the yard. Which problem
should the nurse suspect? Bursitis
Rationale:
Bursitis is common in adults older than age 40 years and with repetitive motion, such as raking.
Plantar fasciitis occurs as a stabbing pain at the heel caused by straining the ligament that supports
the arch. Achilles tendonitis is an inflammation of the tendon that attaches the calf muscle to the heel
bone and causes pain with walking or running. A sprained ligament occurs when a ligament is
stretched or torn from a direct injury or sudden twisting of the joint, not from repetitive motion.
How would the nurse explain the process of normal bone remodeling? Osteoblasts deposit
new bone.
Rationale:
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; however, they are not involved with bone remodeling.
A patient is scheduled for arthrocentesis arrives at the outpatient surgery unit and
states, “I do not want this procedure done today.” Which response by the nurse
is most appropriate? “Tell me what your concerns are about this procedure.”
Rationale:
The nurse should use therapeutic communication to determine the patient’s concern about the
procedure. The nurse should not provide false reassurance. It is not appropriate for the nurse to
conclude the patient is concerned about pain or assume the patient is asking to reschedule the
procedure.
The nurse admits a 55-year-old woman with multiple sclerosis to a long-term care facility.
Which finding represents a safety concern? Ataxic gait
Rationale:
An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in those with gait instability
and visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention,
radicular pain) may also occur in the patient with multiple sclerosis.
An 82-yr-old patient is frustrated by loose abdominal tissue and rigid hips. How should
the nurse respond? “Decreased muscle mass and strength and increased hip rigidity are
expected with aging.”
Rationale:
The musculoskeletal system’s normal changes of aging include decreased muscle mass and
strength; increased rigidity in the hips, neck, shoulders, back, and knees; decreased fine motor
dexterity; and slowed reaction times. Going on a diet and exercising will help but not stop these
changes. Telling the patient “Something must be wrong with you…” is untrue and will not be helpful
to the patient’s frustrations.
A patient is about to have a bone scan. In teaching the patient about this procedure, the
nurse should include what information? “You will need to drink increased fluids after the
procedure.”
Rationale:
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 are required. Only mild pain may be
associated with bone scans related to 1 hour of lying supine.
A patient admitted with cellulitis and probable osteomyelitis received an injection of
radioisotope at 9:00 AM prior to a bone scan. Which statement by the nurse is correct?
“The isotopes injected for the scan are not harmful to you.”
Rationale:
The isotope does not harm the patient. A technician 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. Increased isotope uptake indicates osteomyelitis. Bone scans are completed in about 1
hour.
A 63-yr-old woman with a kidney transplant has been taking prednisone (Deltasone) daily
for several years to prevent organ rejection. Which finding is most important for the
nurse to communicate to the health care provider? Back or neck pain
Rationale:
Osteoporosis with fractures is a serious complication of corticosteroid therapy. The ribs and
vertebrae fractures cause back and neck pain. Ataxic (staggering) gait is an adverse effect of
phenytoin, an antiseizure medication. A rare adverse effect of ciprofloxacin and other
fluoroquinolones is tendon rupture, usually the Achilles tendon. Antipsychotics and antidepressants
may cause tardive dyskinesia, characterized by involuntary movements of the tongue and face.
When administered long-term, which medication requires ongoing musculoskeletal
assessment? Corticosteroids
Rationale:
Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. βBlockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with
damage to the musculoskeletal system.
The nurse understands that patients have the most difficulties with diarthrodial
joints. Which joints are included in this group? (Select all that apply.) Hinge joint of
the knee
Gliding joints of the wrist and hand
Ball and socket joint of the shoulder or hip
Rationale:
The diarthrodial joints include the hinge joint of the knee and elbow, ball and socket joint of the
shoulder and hip, pivot joint of the radioulnar joint, and condyloid, saddle, and gliding joints of the
wrist and hand. The ligaments and cartilaginous connective tissue joining the vertebrae and pubis
joint and the fibrous connective tissue of the skull are synarthrotic joints.
Chapter 63
The nurse is planning health promotion teaching for a 45-yr-old patient with asthma who
has low back pain from herniated lumbar disc. What activity would the nurse include in
an individualized exercise plan for the patient? Walking
Rationale:
The patient would benefit from an aerobic exercise that considers the patient’s health status and fits
the patient’s lifestyle. The best exercise is walking, which builds strength in the back and leg
muscles without putting undue pressure or strain on the spine. If the patient has exercise-induced
asthma, the nurse would recommend use of a rescue inhaler prior to exercise. Yoga, calisthenics,
and weightlifting would all put pressure on or strain the spine.
The nurse is reinforcing health teaching about osteoporosis with a 72-yr-old patient
admitted to the hospital. What should the nurse explain to the patient? Even with a family
history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and
exercise.
Rationale:
The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements or
foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with
bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the
associated increased risk of heart disease and breast and uterine cancer.
A 67-yr-old patient hospitalized with osteomyelitis has an order for bed rest with
bathroom privileges and elevation of the affected foot on 2 pillows. The nurse would
place the highest priority on which intervention? Perform frequent position changes and
range-of-motion exercises.
Rationale:
The patient is at risk for atelectasis of the lungs and contractures because of prescribed bed rest.
For this reason, the nurse should place the priority on changing the patient’s position frequently to
promote lung expansion and performing range-of-motion exercises to prevent contractures.
Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not
be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with
the bed rest. Dangling the legs every 2 to 4 hours may be too painful.
A 24-yr-old male patient has come to the clinic with a gradual onset of pain and swelling
in the left knee. The patient is diagnosed with osteosarcoma without metastasis.
Chemotherapy is ordered before surgery. How would the nurse explain the reason for
preoperative chemotherapy? “Chemotherapy is being used to decrease the tumor size.”
Rationale:
Preoperative chemotherapy is used to decrease the tumor size before surgery. The chemotherapy
will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct
chemotherapy after amputation or limb salvage has increased 5-year survival rates in people without
metastasis. Chemotherapy is not used to decrease pain before or after surgery.
A 58-yr-old woman with breast cancer is admitted for severe back pain related to a vertebral
compression fracture. The patient’s laboratory values include serum potassium of 4.5 mEq/L,
serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms
would the nurse expect the patient to exhibit?
Nausea, vomiting, and altered mental status
Rationale:
Breast cancer can metastasize to the bone, with vertebrae as a common site. Pathologic fractures at
the site of metastasis are common because of a weakening of the involved bone. High serum
calcium results as calcium is released from damaged bones. Normal serum calcium is 8.6 to 10.2
mg/dL. Manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g.,
lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma).
Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms
of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include
muscle stiffness, dysphagia, and dyspnea.
The nurse determines dietary teaching for a 75-yr-old patient with osteoporosis has been
successful when the patient selects which meal as highest in calcium? Sardine (3 oz)
sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk
Rationale:
The highest calcium content is present in the lunch containing milk and milk products (yogurt) and
small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread,
broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss
cheese and American cheese have more calcium but not as much as the sardines, yogurt, and milk.
The nurse receives report from the licensed practical nurse (LPN/VN) about care
provided to patients on the orthopedic surgical unit. It is most important for the nurse to
follow up on which statement? “The patient who had spinal surgery 3 hours ago is reporting a
headache and has clear drainage on the dressing.”
Rationale:
After spinal surgery, there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or
leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The
drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience
interference with bowel function for several days. Postoperatively most patients require opioids such
as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain
management during this time. After cervical spine surgery, patients often wear a soft or hard cervical
collar to immobilize the neck.
A patient who has low back pain from a herniated lumbar disc is having muscle spasms.
Which nursing intervention would be most appropriate? Elevate the head of the bed 20
degrees and flex the knees.
Rationale:
To reduce pain, the nurse should elevate the head of the bed 20 degrees and have the patient flex
the knees to avoid extension of the spine. The slight flexion provided by this position often is
comfortable for a patient with a herniated lumbar disc. ROM to the lower extremities will be limited to
prevent extremes of spinal movement. Reverse Trendelenburg and a pillow under the patient’s
upper back will more likely increase pain.
The nurse is caring for patients in a primary care clinic. Which patient is most at risk to
develop osteomyelitis caused by Staphylococcus aureus? A 32-yr-old male patient with type
1 diabetes and stage 4 pressure injury
Rationale:
Osteomyelitis caused by S. aureus is usually associated with a pressure ulcer or vascular
insufficiency related to diabetes. Osteomyelitis caused by Staphylococcus epidermidis is usually
associated with indwelling prosthetic devices from joint arthroplasty. Osteomyelitis caused
by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused
by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with
osteomyelitis.
During a health screening event, which assessment finding in a 61-yr-old patient would
alert the nurse to the possible presence of osteoporosis? Measurable loss of height
Rationale:
A gradual but measurable loss of height and the development of kyphosis (“dowager’s hump”) are
indicative of the presence of osteoporosis. Bowed legs may be caused by abnormal bone
development or rickets but are not indicative of osteoporosis. Lack of calcium and Vitamin D intake
may cause osteoporosis but are not indicative of its presence. A wide gait is used to support balance
and does not indicate osteoporosis.
The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the
tibia. When completing a focused assessment, which symptom should the nurse expect?
Localized pain and warmth
Rationale:
Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or
spread from another part of the body. Because it is an infection, the patient will exhibit typical signs
of inflammation and infection, including localized pain and warmth. Nausea and vomiting and
paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized rather than
generalized throughout the leg.
When the patient is diagnosed with muscular dystrophy, what information should the
nurse include in the teaching plan? Remain active to prevent skin breakdown and respiratory
complications.
Rationale:
With muscular dystrophy, the patient must remain active for as long as possible. Prolonged bed rest
should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be
used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP)
may be used as respiratory function decreases before mechanical ventilation is needed to sustain
respiratory function.
The nurse has reviewed proper body mechanics with a patient who has a history of low
back pain caused by a herniated lumbar disc. Which patient statement indicates a need
for further teaching? “I should pick up items by leaning forward without bending my knees.”
Rationale:
The patient should avoid leaning forward without bending the knees. Bending the knees helps to
prevent lower back strain and is part of proper body mechanics for lifting. Sleeping on the side or
back with hips and knees bent and standing with a foot on a stool will decrease lower back strain.
Back strengthening exercises are done twice a day once symptoms subside.
Which nursing intervention is most appropriate when turning a patient after spinal
surgery? Placing a pillow between the patient’s legs and turning the body as a unit
Rationale:
Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine
in good alignment and reduces pain and discomfort after spinal surgery. The other interventions will
not maintain proper spine alignment and may cause spinal damage.
The nurse is admitting a patient with a history of a herniated lumbar disc and low back
pain. Which action would likely aggravate the pain? Bending or lifting
Rationale:
Back pain related to a herniated lumbar disc is aggravated by events and activities that increase
stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with
the knee straight (straight leg-raising test). Moist heat, sleeping position, and ability to sit in a fully
extended recliner do not aggravate the pain of a herniated lumbar disc.
An older adult is diagnosed with Paget’s disease. Which finding would indicate
improvement in the condition? Lower serum alkaline phosphatase
Rationale:
Paget’s disease is characterized by excessive bone resorption and replacement of normal marrow
with vascular, fibrous connective tissue. A normalizing alkaline phosphatase indicates bone
resorption has slowed or stopped. Additional characteristics of the disease include bone pain, a
waddling gait, loss of stature, and curved bones. Uptake of radiolabeled bisphosphonate indicates a
bone is affected.
A patient with acute osteomyelitis asks the nurse how this problem will be treated
initially. Which response by the nurse is most appropriate? “IV antibiotics are usually
required for several weeks.”
Rationale:
The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy.
However, as many as 3 to 6 months may be required. Bone is denser and less vascular than other
tissues, and it takes time for the antibiotic therapy to eradicate all microorganisms. Surgery may be
used for chronic osteomyelitis, to include debridement of the devitalized, infected tissue and
irrigation of the affected bone with antibiotics.
The nurse is admitting a patient who reports the new onset of lower back pain. To
distinguish between the pain of a lumbar herniated disc from other causes, what is
the best question for the nurse to ask the patient? “Does the pain radiate down the buttock or
into the leg?”
Rationale:
Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the
sciatic nerve. It is often described as traveling through the buttock to the posterior thigh or down the
leg. This is because the herniated disc causes compression on spinal nerves as they exit the spinal
column. Time of occurrence, type of pain, and pain relief questions do not elicit differentiating data.
The nurse provides instructions to a 30-yr-old office worker who has low back pain. Which
statement indicate additional patient teaching is required?
“Acupuncture to the lower back would cause irreparable nerve damage.”
Rationale:
Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine
needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic
purposes.
The nurse is caring for a patient hospitalized with a herniated lumbar disc and an
exacerbation of chronic bronchitis. Which breakfast choice would be most appropriate
for the patient to select from the breakfast menu? Bran muffin
Rationale:
Each meal should contain one or more sources of fiber to reduce the risk of constipation and
straining with defecation, which increases back pain. A patient with chronic breathing difficulties also
will benefit from regularity and ease of bowel evacuation. In addition, if lumbar nerve compression is
present, bowel and bladder function may be impaired. Bran is a typical high-fiber food choice and is
an appropriate selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white
toast do not have as much fiber.