Exam 4 - Musculoskeletal

Question 1

What could happen to a client if his or her fractured femur is not reduced (set) & immobilized properly?

Answer 1

• Bone is unlikely to heal straight and regain full function
• Non-union - failure of bone ends to grow together - gaps fill with dense fibrous and fibrocartilaginous tissue
• Delayed union - does not occur until 8-9 months after fracture
• Malunion - healing of bone in nonatomic position
• Avascular necrosis - disruption of blood supply

Question 2

Inflammatory joint disease

Basic pathophysiology & general clinical manifestations

Answer 2

• Inflammatory joint disease is an umbrella term; commonly called arthritis
• Can be triggered by an autoimmune response, excessive use, increased physical stress, or injury
• Inflammatory changes or destruction in synovial membrane or articular cartilage and by systemic signs of inflammation
• Fever, leukocytosis, malaise, anorexia, and hyperfibrinogenemia
• Infectious or noninfectious

(Slide 114)

Question 3

Osteoporosis – S/S & which is most common

Answer 3

No symptoms in early stages but once bones have been weakened:

• ** Bone deformity #1
• Back pain, caused by fractured or collapsed vertebrae
• Loss of height over time
• Stooped posture
• Bone fractures occur more easily
• Pain related to fracture: femur neck (“broken hip”), humerus, vertebrae, ribs, distal radius (Colles fracture)

Question 4

Osteoarthritis - Clinical manifestations

• Be able to distinguish between the types of arthritis

Answer 4

• Progressive deterioration of articular cartilage
• Causes bone build-up and loss of articular cartilage in peripheral & axial joints
• Affects weight-bearing joints and joints with greatest stress – hips, knees, lower vertebral column, hands (*Relieved with rest)
• Stiffness with movement
• Enlargement of the joint
• Tenderness
• Limited motion deformity

Question 5

Basic pathophysiology of ankylosing spondyltis

Answer 5

• Begins with inflammation of fibrocartilage, especially vertebrae & sacroiliac joint
• Enthesis: primary proposed site, where ligaments, tendons, joint capsule insert into bone
• Inflammatory cells infiltrate & erode fibrocartilage
• Repair begins – scar tissue ossifies & calcifies – joint eventually fuses
• Results in loss of normal lumbar curvature

Question 6

Clinical manifestation of rheumatoid arthritis

Answer 6

• Morning stiffness that may last for hours
• Fever, fatigue, weight loss
• Firm bumps of tissue under skin on arms (rheumatoid nodules)

Question 7

Gouty arthritis

Know the basics of the pathogenesis of gout on Porth page 1151, 1st & 2nd paragraph under “Pathogenesis”

Answer 7

• Elevation of uric acid – overproduction of purines
• Decrease salvage of free purine bases
• Decreased urinary excretion
• Inadequate elimination by kidneys
• Augmented breakdown of nucleic acids as a result of increased cell turnover
• May be result of enzyme defect

Question 8

Need to know normal lab ranges for calcium & phosporous from the NIU lab sheet

Answer 8

Calcium - 9.0 - 10.5 mg/dL

Phosphorous - 3.0 - 4.5 mg/dL

Question 9

Need to know the normal lab range for uric acid

Know which of these lab values are elevated gouty arthritis

Answer 9

Uric acid is elevated in gouty arthritis

3.5 - 7.2 uric acid

> 7 : crystals start to form

Question 10

Osteosarcoma - be able to recognize the descriptions of other bone cancers

Answer 10

• 38% of bone tumors
• Aggressive
• Begins in bone cells
• Predominant in adolescents and young adults
• 50% occur around knees
• Masses of osteoid (“streamers” – non-calcified bone matrix & callus)

Question 11

Clinical manifestations of fibromyalgia

Answer 11

• Widespread muscular pain and fatigue (does not affect joints) – constant dull muscle ache
• Manifestations vary based on weather, stress, fatigue, physical activity, time of day
• Sleep disturbances, depression, IBS, headaches, memory problems may also be seen
• Associated with RA, SLE, ankylosing spondylitis

Question 12

Clinical manifestations/physical assessment for sciolosis

Answer 12

• Spinal deformity most characteristic – spine looks like “C” or “S”
• Uneven shoulders or iliac crest, prominent scapula on convex side of curve, malalignment of spinous processes
• Assess: Adams forward bend test enables physician to measure curvature with scoliometer
  
  • Reading greater than 10 – refer to physician
  • Confirm with CT/MRI/myelography

Question 13

Osteoporosis - Know how hormones influence osteoblasts & osteoclasts

Answer 13

• Osteoporosis is bone growth/bone breakdown out of sync (decrease in osteoblast activity or increase in osteoclast activity)
• Osteoblasts secrete RANK ligand which control osteoclasts
• During bone growth, OPG blocks RANK ligand  osteoclasts don’t function
• In post-menopausal women, as estrogen declines, RANK ligand expression increases
• THEREFORE: Lower estrogen -> Increased RANK ligand -> overwhelms OPG -> increased osteoclast formation
• RANK ligand is key link between reduced estrogen levels and osteoclast-mediated bone loss

Question 14

In taking the health history of a client with severe painful osteoarthritis, the nurse would expect to report which of the following?

1. A gradual onset of the disease, with involvement of weight-bearing joints
2. A sudden onset of the disease, with involvement of all joints
3. Complaints of joint stiffness after periods of activity
4. Pain that improves with use of the joint

Answer 14

1. A gradual onset of the disease, with involvement of weight-bearing joints

Osteoarthritis has a gradual onset and affects weight-bearing joints with pain that is more pronounced after exercise. The onset of osteoarthritis is gradual, not sudden. The client will usually complain of increased stiffness in the morning and also following periods of inactivity, with improvement following activity. Joint pain generally worsens with joint use and in the early stages of osteoarthritis, joint pain is relieved by rest.

Question 15

For a client with severe painful osteoarthritis, a regimen of heat, massage and exercise will:

1. Help relax muscles and relieve pain and stiffness
2. Restore range of motion previously lost
3. Prevent the inflammatory process
4. Help the client cope with pain effectively

Answer 15

1. Help relax muscles and relieve pain and stiffness

Physical therapy relaxes muscles and relieves the aching and stiffness of the involved joints. It usually does not restore lost range of motion, and it does not prevent inflammation. Physical therapy does make the client more comfortable, but it does not assist in coping with pain.

Question 16

A client is confined to bed with a fracture of the left femur. He begins receiving subcutaneous heparin injections. What is the purpose of this medication?

1. To prevent thrombophlebitis and pulmonary emboli associated with mobility
2. To promote vascular perfusion by preventing formation of microemboli in the left leg
3. To prevent venous stasis, which promotes vascular complications associated with mobility
4. To decrease the incidence of fat emboli associated with long bone fractures

Answer 16

1. To prevent thrombophlebitis and pulmonary emboli associated with mobility

Heparin is administered prophylactically to prevent thromboembolic complications in clients who are immobilized for prolonged periods. It is not effective in preventing fat emboli or venous stasis or promoting vascular perfusion.

Question 17

A client begins receiving methotrexate (Rheumatrex) for severe symptoms of rheumatoid arthritis. What is the most important information for the nurse to give this client regarding the medication?

1. Take extra fiber and fluids to counteract the constipating effect
2. It is very important to have periodic lab work done
3. Take the drug on an empty stomach
4. Hirsutism and menstrual changes sometimes develop as side effects

Answer 17

2. It is very important to have periodic lab work done

Lab work will need to be done periodically during administration to monitor for the development of anemia, leukopenia, thrombocytopenia, and/or hepatic toxicity. Hirsutism and menstrual changes occur with long-term corticosteroid use. Methotrexate should be given 1 hour before or 2 hours after meals to prevent vomiting when given PO. Antiemetics are given concurrently with the medication.

Question 18

A nurse is conducting health screening for osteoporosis. Which of the following clients is at greatest risk of developing this disorder?

1. A 25-year-old woman who jogs
2. A 36-year-old man who has asthma
3. A 70-year-old man who consumes excess alcohol
4. A sedentary 65-year-old woman who smokes cigarettes

Answer 18

4. A sedentary 65-year-old woman who smokes cigarettes

Risk factors for osteoporosis include female gender, postmenopausal, advanced age, low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide (Lasix) also increase the risk.

Question 19

A client with diabetes mellitus has had a right below-knee amputation. The nurse would assess specifically for which of the following signs because of the history of diabetes?

1. Hemorrhage
2. Edema of the stump
3. Slight redness of the incision
4. Separation of the wound edges

Answer 19

4. Separation of the wound edges

Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative stump edema and hemorrhage are complications in the immediate postoperative period that apply to any client with amputation. Slight redness of the incision is considered normal, as long as it is dry and intact.

Question 20

A nurse is caring for a client with a diagnosis of gout. Which of the following laboratory values would the nurse expect to note in the client?

1. Calcium level of 9.0 mg/dL
2. Uric acid level of 8.6 mg/dL
3. Potassium level of 4.1 mEq/dL
4. Phosphorus level of 3.1 mg/dL

Answer 20

2. Uric acid level of 8.6 mg/dL

In addition to the presence of clinical manifestations, gout is diagnosed with the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL; a normal value ranges from 2.5 to 8 mg/dL. Options 1, 3, and 4 indicate normal laboratory values. Additionally, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.