NCLEX Secrets about Musculoskeletal Injuries
Situation: Mr. Janno Alcasid, overweight, 61 years old, was admitted and diagnosed with osteoarthritis.
1. Mr. Alcasid asks the nurse, "What is osteoarthritis?" Which response from the nurse is correct?
a) your bones are inflamed
b) your weight bearing joints are inflamed
c) you have inflammation in your joints
d) there is shortening of your long bones
2. Which of the following guidelines should a nurse include in the teaching plan for a patient who has osteoarthritis?
a) achieve ideal body weight
b) increase daily calcium intake to 1500 mg
c) maintain a high fiber diet
d) sleep at least 10 hours each day
Situation: Maco, a newly registered nurse, works as a private duty nurse of a 55 year old female Canadian national who has gout.
3. Which of the following nursing diagnoses is a priority for a patient with gout?
a) pain
b) fatigue
c) risk for infection
d) risk for peripheral neurovascular dysfunction
4. The nurse would instruct the patient which of the following to minimize complications?
a) drinking a minimum of 3000 ml of fluid per day
b) eating a minimum of 2500 calories per day
c) walking at least three miles per day
d) resting at least three hours per day
5. Foods allowed in the diet of gout patient include:
a) cheese
b) beef
c) sardines
d) liver
6. The patient is placed on allopurinol (Zyloprim) therapy. To monitor effectiveness of the therapy, the nurse will monitor which the following serum laboratory values?
a) uric acid
b) fasting blood glucose
c) serum calcium
d) alkaline phosphatase
7. A patient with rheumatoid arthritis asks the nurse why she is taking Prednisone (Deltasone) the nurse best response would be that it:
a) enhance the immune system
b) increase bone density
c) decrease inflammation
d) reduce peripheral edema
8. A patient under steroid therapy should be advised by the nurse to:
a) limit carbohydrates in the diet
b) take the medication on an empty stomach
c) avoid individuals who have infections
d) stop the medication when symptoms have subsided
NCLEX Secrets about Musculoskeletal Injuries:
ANSWERS AND RATIONALE
1) B
- Osteoarthritis, also known as hypertrophic arthritis, osteoarthritis, senescent arthritis and degenerative joint disease is characterized by destruction of the articular cartilage, which becomes opaque, yellow, soft, weak and deteriorated. It is followed by thickening of bone under the cartilage and formation of osteophytes or bone spurs. Unlike RH, osteoarthritis is not a systemic disease and affects only the joint and its surrounding tissue. This disorder commonly occurs in the 50-70 year age group but women are more severely affected.
The Signs and Symptoms of Osteoarthritis include:
- pain - worse with weight bearing, improves with rest may occur with paresthesia
- joint swelling and enlargement - may be from inflammatory exudates entering joint capsule causing an increase in synovial fluid or from fragments of osteophytes entering synovial cavity
- decreased ROM - depends on the amount of destroyed cartilage
- muscular atrophy - from disuse, joint instability and deformity
- crepitus - must be present on movement of the joint
- joint stiffness - worse in the morning and after a period of rest and disuse
- heberden's nodes - bony protuberances occurring on the dorsal surface of the distal interphalangeal joints of the fingers
- bouchard's nodes - bony protruberances occurring on the proximal interphalangeal joints of fingers
- coxaarthrosis - pain in the hip on weight bearing with pain progressing to include the groin and medial knee pain and limited range of motion
- varus (bowlegs) or valgus (knock kneed)
- the primary cause of arthritis is not yet known but it is often-associated with obesity, aging, trauma, fractures, and infections. Osteoarthritis is a wear and tear disease of the joints. The more pressure it takes the more severe and the faster is the progression of the disease. Thus, one of the important aspects of management if the patient is obese is to lose weight to lessen the pressure on the joints
3) A
- Gouty arthritis is a metabolic disorder characterized by accumulation and deposition of uric acid crystals, called tophi, in tissues especially in joints that results in inflammatory response. It is caused by prolonged hyperuricemia due to problems in synthesizing purines or by poor excretion of uric acid by the kidney. This disorder is more common in men, with onset around age 50.
The immediate problem of patient suffering from gout is the acute pain experienced on affected joints such as the great toe, feet, ankles, or knees.
Other signs and symptoms include:
- malaise
- pruritus
- headache
- elevated serum uric acid
- presence of tophi
- positive monsodium urate crystals in synovial fluid
- inflammation of affected joint
- provide bed rest
- use bed cradle to support bed sheets and keep pressures of sheets off joint
- perform range of motion exercise gently
- carefully align joints so they are slightly flexed
- administer medications
- renal urate lithiasis (kidney stones) may result from precipitation of uric acid in the presence of low urinary pH. This can be avoided by allowing the patient liberal fluid intake to promote urinary excretion of uric acid.
5) A
- preventive measures for gout:
- uric acid is formed from metabolism of purine. To prevent further formation and accumulation of uric acid, the patient must be advised to stick on a low purine diet. This means that the patient must avoid: sweet breads, yeast, heart, herring, sardines, anchovies, shellfish, heavy alcohol intake
- avoidance of excessive weight gain
- alkaline ash diet to increase the pH of urine to discourage precipitation of uric acid and enhance the action of drugs such as probenicid (Benemid)
- preventive therapy - prevention of future gout attacks is by placing the patient on daily medication that either promote uric acid excretion or prevent uric acid formation. To evaluate the effectiveness of the therapy, serum uric acid level of the patient must be monitored. The medication is effective when uric acid goes down to normal level below 6.9 mg/dl.
7) C
- the main effect of corticosteroids is to supress inflammation. However, this same effect is also one of the main setback of corticosteroid therapy suppression of the inflammatory response also decreases the immune response making the patient susceptible to infection.
8) C
- Long Term Side Effects of Prednisone Therapy
- causes GI irritation so it must be taken with food. Patient may need antacid (must not contain sodium) to prevent ulcer. Give once-daily dose in the morning to lessen toxicity. Maybe diluted in juice or semi-solid food such as apple sauce
- causes sodium and water retention that results in cushinghoid appearance: moon face, buffalo hump, thinning of hair, hypertension and edema. Advise patient on low sodium diet that's high in potassium and protein
- avoid discontinuing abruptly as it can cause adrenal insufficiency and rebound inflammation. Reduce dosage gradually
- can cause glaucoma and cataract so monitor patient for visual disturbances and advise to have annual eye exam if on long term therapy
- increases cholesterol and glucose levels so diabetics must increase insulin dosage
- skin tests will be false-negative because it suppresses immune response
- avoid active immunization while under therapy because patient is immunosuppressed
- causes hypocalcemia and hypokalemia and increased urine calcium levels, causes osteoporosis so patient needs Vitamin D and calcium supplement
- will decrease iodine uptake and protein-bound iodine levels in thyroid function test
- tell patient to report: slow healing, exposure to infection, depression, insomnia, psychotic symptoms, weakness and fatigue, dizziness, joint pain, fever, anorexia and fainting
- always give by deep IM in gluteal muscle to prevent sterile abscess if given by subcutaneous and rotate injection sites route to prevent tissue atrophy
- always give the lowest dose to minimize toxicity
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