MSN Exam for Musculoskeletal Problems

EXPLANATION

 

✔Correct answer:

Replacing the patient's wrist splint in a hyperextension position. Replacing the patient's wrist splint in a hyperextension position necessitates immediate intervention. Proper positioning of the wrist is crucial in the treatment and management of carpal tunnel syndrome. A wrist splint should maintain the wrist in a neutral or slightly extended position to reduce pressure on the median nerve. Placing the wrist in hyperextension can increase pressure on the median nerve, potentially worsening symptoms and delaying recovery. As the charge nurse, it is important to intervene to correct the position of the splint and provide guidance or additional training to the nursing assistant to ensure the patient's safety and comfort.

Think of the wrist like a water hose. When the hose is laid out straight, water can flow smoothly. But if you bend the hose too much (hyperextension of the wrist), it can kink and block the flow of water (blood and nerve signals). The splint should keep the wrist like a straight hose—not bent too much—so everything can flow as it should.

In carpal tunnel syndrome, the median nerve, which runs from the forearm into the palm of the hand, is compressed at the wrist in the carpal tunnel. This compression leads to symptoms such as pain, numbness, and tingling in the hand and arm. The goal of splinting is to keep the wrist in a neutral or slightly extended position to minimize pressure on the median nerve and allow it to heal. Hyperextension of the wrist can increase the pressure within the carpal tunnel, exacerbating symptoms.

 

✘Incorrect answer options:

Assisting the patient with a bath using warm water. Using warm water for a bath is generally safe and can be soothing unless contraindicated for specific reasons.

Reminding the patient to avoid lifting heavy objects. Advising the patient to avoid activities that can exacerbate symptoms, such as lifting heavy objects, is appropriate and aligns with the management of carpal tunnel syndrome.

Preparing the patient's lunch tray and cutting the meat into smaller pieces. Assisting the patient with meals, especially tasks that may be difficult due to the wrist condition, is a suitable and supportive action for a nursing assistant.

 

References

• American Academy of Orthopaedic Surgeons. (2016). Carpal Tunnel Syndrome. AAOS.
• Porth, C. M., & Matfin, G. (2009). Pathophysiology: Concepts of Altered Health States (8th ed.). Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answer:

Closely monitoring for indications of adequate tissue perfusion. Closely monitoring for indications of adequate tissue perfusion is the most crucial focus for nursing care a day after a below-the-knee amputation. Ensuring good tissue perfusion to the residual limb is critical to promote healing, prevent infection, and prepare the limb for a prosthesis in the future. The nurse should monitor for signs of adequate perfusion such as warm skin temperature, presence of a palpable pulse (if accessible), and healthy skin color. Monitoring for signs of compromised perfusion, such as pallor, mottling, coldness, or delayed capillary refill, is vital for early detection of complications like infection, hematoma, or necrosis.

Think of the blood supply to the limb as water flowing to a garden through a hose. Just as plants need a steady flow of water to stay healthy, the tissues in the residual limb need a steady flow of blood to receive enough oxygen and nutrients for proper healing. Monitoring tissue perfusion is like making sure the water is reaching all parts of the garden efficiently.

After an amputation, the body needs to heal and adjust to the changes in blood flow and tissue structure. Adequate blood supply (perfusion) to the remaining limb is crucial for delivering oxygen and nutrients to support tissue repair and fight off infection. Poor perfusion can lead to tissue death (necrosis), delayed healing, and other serious complications.

 

✘Incorrect answer options:

Facilitating early ambulation for the patient. While early ambulation is important in the recovery process, it might be too early to prioritize this a day after surgery, especially before ensuring that the residual limb is healing properly.

Achieving pain control for any occurring phantom pain. Managing pain, including phantom limb pain, is important, but it may not be the most critical focus immediately after surgery compared to monitoring tissue perfusion to ensure proper healing of the surgical site.

Elevating the residual limb when Jenna is lying flat on her back. Elevating the residual limb can help reduce swelling, but continuous elevation of the limb for prolonged periods right after surgery is no longer universally recommended as it may lead to joint contractures and delay rehabilitation. Monitoring tissue perfusion is generally a more immediate priority.

 

References

• Ziegler-Graham, K., MacKenzie, E. J., Ephraim, P. L., Travison, T. G., & Brookmeyer, R. (2008). Estimating the prevalence of limb loss in the United States: 2005 to 2050. Archives of Physical Medicine and Rehabilitation, 89(3), 422-429.
• Pinzur, M. S., Gold, J., Schwartz, D., & Gross, N. (2006). Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics, 29(9), 842-845.

EXPLANATION

 

✔Correct answer:

The patient is displaying signs of confusion. The nursing assistant should immediately communicate to Nurse Chris if the patient is displaying signs of confusion. Sudden onset of confusion or altered mental status in a patient with a fractured femur can be a symptom of serious complications such as a fat embolism syndrome (FES), especially in the early post-injury period. FES is a rare but serious condition in which fat globules are released into the bloodstream and lodge in the lung capillaries and other organs, leading to respiratory distress, petechial rash, and neurological symptoms including confusion or altered mental status. Early detection and intervention are crucial to manage this potentially life-threatening condition.

Imagine your body as a busy highway with cars (blood cells) smoothly transporting goods (oxygen and nutrients) to different parts of the city (body). If suddenly some roads are blocked by unexpected obstacles (fat globules), the transport of goods becomes inefficient, causing confusion and chaos in the supply chain (body systems). This is similar to how fat emboli can disrupt normal blood flow and cause confusion among other symptoms.

The femur, or thigh bone, is one of the largest bones in the body and has a significant amount of marrow fat. When a fracture occurs, fat from the marrow can enter the bloodstream and form emboli. These emboli can travel to the lungs and other organs, causing inflammation and a blockage of blood flow. The brain is particularly sensitive to changes in blood flow and oxygenation, and reduced blood flow or oxygenation can lead to confusion and other changes in mental status.

 

✘Incorrect answer options:

The patient's blood pressure is recorded at 136/88. While this blood pressure reading is slightly elevated, it's not critically high and not as immediately concerning as a sudden onset of confusion. It should still be monitored.

The patient has successfully voided using the bedpan. This is a normal finding and doesn't typically require immediate notification of the nurse unless there were prior concerns about the patient's ability to void.

The patient is vocalizing complaints of pain. While pain management is important, pain is an expected symptom following a fracture and not as urgently concerning as sudden confusion. However, the nurse should still be informed to properly manage the patient's pain.

 

References

• Giannoudis, P. V., Pape, H. C., & Cohen, A. P. (2005). Review: Fat embolism syndrome. Injury, 36 Suppl 4(Suppl 4), S47–S56.
• Taviloglu, K., & Yanar, H. (2007). Fat embolism syndrome. Surgery Today, 37(1), 5-8.

EXPLANATION

 

✔Correct answer:

Sarah reports feeling pressure and pain under the cast. Sarah reporting feeling pressure and pain under the cast should prompt immediate communication with the physician. After a cast is applied to treat fractures, it's important to monitor for signs of compromised circulation or nerve compression. Pressure and pain under the cast may indicate that the cast is too tight, leading to potential complications such as compartment syndrome, a condition in which increased pressure within the muscles can decrease blood flow and prevent nourishment and oxygen from reaching nerve and muscle cells. It's a medical emergency requiring prompt intervention to prevent permanent damage.

Imagine wearing a pair of shoes that are too tight. At first, it might just feel uncomfortable, but if you keep wearing them, the pressure can cause pain and even harm your feet. Similarly, a cast that's too tight can apply harmful pressure on the injured area, which is why it's crucial to address Sarah's report of pressure and pain immediately.

The forearm is an area prone to compartment syndrome due to its enclosed muscle compartments. A cast that's too tight can impede blood flow, leading to increased pressure within these compartments. This pressure can compress nerves and blood vessels, leading to pain, sensory deficits, and muscle weakness. If not addressed promptly, the reduced circulation can lead to tissue damage and loss of function.

 

✘Incorrect answer options:

Sarah has full movement of all fingers and her thumb. Full movement of fingers and thumb indicates good function and is not a cause for immediate concern.

Sarah's cast appears well-placed, dry, and intact. A well-placed, dry, and intact cast is a sign of a properly maintained cast, which is desirable and does not warrant immediate communication with the physician.

The skin around the cast is pink and warm upon touch. Pink and warm skin around the cast indicates good circulation and is not a cause for immediate concern.

 

References

• von Keudell, A., Weaver, M. J., Appleton, P. T., Bae, D. S., Dyer, G. S., Heng, M., ... & Harris, M. B. (2015). Diagnosis and treatment of acute extremity compartment syndrome. The Lancet, 386(10000), 1299-1310.
• McQueen, M. M., & Duckworth, A. D. (2019). Diagnosis of acute compartment syndrome. Journal of Bone and Joint Surgery. American Volume, 101(7), 623-628.

EXPLANATION

 

✔Correct answer:

"I take my ibuprofen first thing in the morning." The statement, "I take my ibuprofen first thing in the morning," indicates that Mrs. Johnson may need further education regarding the proper use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, especially considering her age and diagnosis of osteoporosis. Taking NSAIDs on an empty stomach can increase the risk of gastrointestinal (GI) irritation or ulcers, which can be a significant concern in elderly patients. It's generally recommended to take NSAIDs with food or milk to help minimize potential GI side effects. Nurse Caroline should use this opportunity to educate Mrs. Johnson about the importance of taking ibuprofen with food or after a meal to protect her stomach lining.

Think of ibuprofen like a powerful cleaning agent that can clean stains but might also damage a delicate fabric if not used properly. Similarly, while ibuprofen can help with pain and inflammation, it can irritate the stomach lining if not taken with food, much like how a strong cleaner needs to be used carefully to avoid damage.

Ibuprofen is an NSAID that works by blocking the production of prostaglandins, substances in the body that cause inflammation and pain. While effective for pain relief, NSAIDs can also reduce the production of protective mucus and bicarbonate in the stomach, potentially leading to irritation of the stomach lining, ulcers, and even bleeding, especially in older adults or those with a history of GI problems. Taking NSAIDs with food can help mitigate these effects by buffering the stomach lining and reducing direct irritation.

 

✘Incorrect answer options:

"My daughter has taken away all the throw rugs from my house." Removing throw rugs is a good safety measure to prevent falls, especially in patients with osteoporosis who are at higher risk of fractures.

"I make sure to rest in my recliner chair for at least one hour every day." Resting and avoiding excessive strain are important, but it's also essential for patients with osteoporosis to engage in weight-bearing and muscle-strengthening exercises as tolerated. This statement doesn't necessarily indicate a misunderstanding unless it's interpreted as excessive inactivity.

"My husband assists me with range-of-motion exercises every afternoon." This statement indicates a good understanding of the importance of maintaining mobility and engaging in physical activity, which is beneficial for bone health and overall well-being.

 

References

• Rosen, H. N., & Drezner, M. K. (2021). Overview of the management of osteoporosis in postmenopausal women. In S. L. Greenspan & A. L. Schafer (Eds.), UpToDate.
• Goodman & Gilman's The Pharmacological Basis of Therapeutics (13th ed.). (2018). McGraw-Hill Education.

EXPLANATION

 

✔Correct answer:

The patient will no longer require any pain medication post-surgery. The instruction that the patient will no longer require any pain medication post-surgery is incorrect and should not be included while directing the LPN/LVN. It's unrealistic to assume that a patient will not require pain management after undergoing an open carpal tunnel release surgery. Pain management is a crucial aspect of postoperative care to ensure patient comfort, promote healing, and facilitate recovery. The LPN/LVN should be prepared to monitor the patient's pain levels and administer pain medication as prescribed and as needed within their scope of practice, under the supervision of an RN.

Think of the surgery like fixing an old, squeaky door (the carpal tunnel) in your house. Even after the repair (surgery), the area around the doorframe (wrist area) may still be tender and sore from the work done. Just like you might need some pain relief after a hard day of manual work, the patient might need medication to manage the pain after the surgical intervention.

Open carpal tunnel release surgery involves cutting the transverse carpal ligament to relieve pressure on the median nerve. Postoperative pain is expected as the surgery involves incisions and disturbance of the tissues. Pain management post-surgery is essential to ensure comfort, promote healing, and facilitate rehabilitation exercises. Effective pain control can also prevent complications such as chronic pain syndromes or delayed return to daily activities.

 

✘Incorrect answer options:

Monitor the patient's vital signs at 15-minute intervals for the first hour post-surgery. This is a standard practice in the immediate postoperative period to ensure the patient's stability and to quickly identify any complications.

Inspect the surgical dressing for any signs of drainage and to ensure it is not too tight. Monitoring the surgical dressing for drainage and ensuring it's not too tight are important parts of postoperative care to prevent complications such as infection or compromised circulation.

Assess the neurovascular status of the patient's fingers on an hourly basis. Regular assessment of neurovascular status is critical after hand surgery to ensure there is no nerve damage or compromised blood flow to the fingers.

 

References

• Keith, M. W., Masear, V., Amadio, P. C., Andary, M., Barth, R. W., Graham, B., ... & Watters, W. C. (2009). Treatment of carpal tunnel syndrome. The Journal of the American Academy of Orthopaedic Surgeons, 17(6), 397-405.
• American Society for Surgery of the Hand. (n.d.). Carpal Tunnel Release.

EXPLANATION

 

✔Correct answer:

You may experience pain and numbness for a period ranging from several days to weeks post-surgery. Nurse Lisa should emphasize to Jennifer that it is normal to experience some pain and numbness in the affected hand and wrist for a period ranging from several days to weeks after endoscopic carpal tunnel release surgery. While this minimally invasive surgery typically results in less postoperative pain and a quicker recovery compared to open surgery, it is still common for patients to experience some discomfort, numbness, or paresthesia during the healing process. This is due to the disturbance of the tissues during surgery and the time it takes for the median nerve and surrounding tissues to recover. Setting realistic expectations about the recovery process is crucial to ensure that the patient is prepared and understands that some symptoms might persist for a while post-surgery.

Think of the surgery like repairing a damaged road. Just after the repair work is done, the road might still have some uneven surfaces or loose gravel, making the drive a bit bumpy. Similarly, right after carpal tunnel surgery, the hand might still have some 'bumps' in the form of pain or numbness as it heals and returns to normal function.

Endoscopic carpal tunnel release surgery involves cutting the transverse carpal ligament to relieve pressure on the median nerve. Post-surgery, the body initiates a healing process, which involves inflammation and remodeling of the affected tissues. The healing process, along with the initial surgical trauma to the tissues, can result in lingering symptoms such as pain, numbness, or tingling in the hand and wrist. Over time, as the nerve recovers and the inflammation subsides, these symptoms typically diminish, but it's important for patients to be aware that this process may take several days to weeks.

 

✘Incorrect answer options:

You will be fully independent and won't require any assistance immediately post-surgery. This statement might not be accurate as the patient may require assistance with certain activities, especially those that involve the affected hand, during the initial recovery period.

All pain and paresthesia symptoms will completely disappear right after surgery. It's important to set realistic expectations. While many patients experience significant relief from symptoms after carpal tunnel release, immediate complete resolution of all symptoms is not guaranteed.

The postoperative dressing will be sizable and may show some dots of drainage. While it's important to discuss wound care, describing the postoperative dressing as "sizable" may not be accurate for endoscopic carpal tunnel release surgery, which typically involves smaller incisions and less invasive techniques compared to open surgery.

 

References

• Keith, M. W., Masear, V., Amadio, P. C., Andary, M., Barth, R. W., Graham, B., ... & Watters, W. C. (2009). Treatment of carpal tunnel syndrome. The Journal of the American Academy of Orthopaedic Surgeons, 17(6), 397-405.
• American Society for Surgery of the Hand. (n.d.). Carpal Tunnel Release. Retrieved from [source].

EXPLANATION

 

✔Correct answer:

"The cause of phantom limb pain isn't entirely understood and can't be fully explained by any single theory." Nurse Oliver's most accurate response would be to explain that the cause of phantom limb pain isn't entirely understood and can't be fully explained by any single theory. Phantom limb pain is a complex phenomenon and is thought to result from a mix of physical and psychological factors. Theories suggest it may involve mixed signals from the brain or spinal cord, but the exact mechanisms are still not fully known. Recognizing the complexity of the condition validates the patient's experience and avoids oversimplification.

Imagine you have an alarm system in your house (the nervous system) that's still set to protect a room that was removed (the amputated limb). Sometimes, the system might falsely detect an intruder (pain signals) in that non-existent room due to some wires being crossed (nerve changes). Just like the alarm system might need adjustments after the room is gone, the body needs time to readjust its signaling pathways after an amputation.

After an amputation, nerve endings at the site of the surgery might continue to send pain signals to the brain, which interprets them as coming from the amputated limb. Changes in the nervous system and brain may contribute to how pain is experienced. The brain's representation of the body can take time to adjust to the changes, which might lead to the sensation of pain or presence in the absent limb. Various treatments, including medications, physical therapy, and nerve stimulation, aim to alleviate this pain by interrupting or modifying the pain signals.

 

✘Incorrect answer options:

 "This type of pain isn't real; it's just pain that your brain remembers." This statement could be perceived as dismissive of the patient's pain. Phantom limb pain is a recognized medical condition and very real to the patient experiencing it.

"Your body is under the impression that your leg is still there, hence the pain." While this statement touches on a component of the theory behind phantom limb pain, it oversimplifies the condition and doesn't fully capture the complexity of the phenomenon.

"This pain won't hinder you from performing your daily activities." This statement might not be accurate and could downplay the impact of phantom limb pain. The intensity of phantom limb pain can vary greatly and might indeed interfere with daily activities for some individuals.

 

References

• Flor, H. (2002). Phantom-limb pain: characteristics, causes, and treatment. The Lancet Neurology, 1(3), 182-189.
• Subedi, B., & Grossberg, G. T. (2011). Phantom limb pain: mechanisms and treatment approaches. Pain Research and Treatment, 2011.

EXPLANATION

 

✔Correct answer:

Assisting the patient in walking to the restroom and along the hallways. Assisting the patient in walking to the restroom and along the hallways is an appropriate task to delegate to a nursing assistant. Nursing assistants are trained to provide basic patient care, including helping patients with mobility and ensuring safety during ambulation. This task does not require the clinical judgment or assessment skills of a registered nurse and falls well within the scope of practice for a nursing assistant. The nursing assistant can ensure that the patient is safe while walking, use gait belts or other assistive devices as needed, and be there to support the patient, preventing falls.

Think of the nursing team as a relay race team. Each member has a specific role or distance they cover. Nurse Hannah is like the team captain who plans the strategy (care plan) and makes sure each runner knows their part. Delegating the task of assisting the patient in walking is like passing the baton to the nursing assistant, who is well-trained for this part of the race (providing direct, basic patient care).

Osteoporosis makes bones weak and more likely to break. Patients with osteoporosis are at an increased risk of falls, which can lead to fractures and other injuries. Assisting patients with ambulation helps to ensure they can move safely without putting undue stress on their bones. Proper support and supervision during walking can prevent falls and the serious consequences that can result, especially in elderly patients.

 

✘Incorrect answer options:

Collaborating with the physical therapy team to supply the patient with a walker. This task involves coordination with other healthcare professionals and may require an understanding of the patient's specific mobility needs and therapy goals, which is more suitable for a registered nurse or a physical therapist.

Evaluating the patient's environment for factors that could increase the risk of falls. This task requires a detailed assessment and clinical judgment to identify potential hazards and implement appropriate interventions, which is within the scope of practice of a registered nurse.

Assessing the patient's gait, balance, and levels of fatigue during ambulation. This assessment requires clinical judgment and expertise to interpret findings and make decisions about the patient's care plan, which should be performed by a registered nurse or a physical therapist.

 

References

• Perry, A. G., Potter, P. A., & Ostendorf, W. (2018). Clinical Nursing Skills and Techniques (9th ed.). Elsevier.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (9th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

Assist the patient with daily self-care activities such as bathing and eating. Assisting the patient with daily self-care activities such as bathing and eating is the most appropriate task to delegate to a nursing assistant. Nursing assistants are trained to help with the basic day-to-day care of patients, including helping with activities of daily living (ADLs). This support is especially important for a patient with carpal tunnel syndrome, who may have difficulty performing these tasks due to pain, numbness, or weakness in the hand and wrist.

Imagine the patient's affected hand is like a tool that's temporarily out of service. Just like you might need someone to help you if your dominant hand was unavailable (say, to open jars or tie your shoes), the patient needs assistance with daily activities that are challenging due to the limitations caused by carpal tunnel syndrome.

Carpal tunnel syndrome occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist. The symptoms, including pain, numbness, and tingling, can impair the patient's ability to perform fine motor tasks, making assistance with ADLs potentially necessary.

 

✘Incorrect answer options:

Conduct an assessment of the patient's wrist and hand for signs like discoloration and brittle nails. This task involves assessment and clinical judgment, which are responsibilities of the registered nurse and should not be delegated to a nursing assistant.

Conduct a test to evaluate painful tingling sensations in the patient's four digits of the affected hand. This task likely refers to conducting a specific diagnostic or neurological test, which is beyond the scope of practice for a nursing assistant and requires the clinical knowledge and judgment of a nurse or physician.

Begin the procedure for applying a splint to immobilize the patient's wrist during daytime hours. Applying a splint is a skilled task that requires specific knowledge about the patient's condition and how to properly fit and apply the splint. This task should be performed by a healthcare professional with specific training in this area, such as a nurse or a physical therapist.

 

References

• Porth, C. M., & Matfin, G. (2009). Pathophysiology: Concepts of Altered Health States (8th ed.). Lippincott Williams & Wilkins.
• Bickley, L. S., & Szilagyi, P. G. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

EXPLANATION

 

✔Correct answer:

Expect limitations in hand movements for approximately 4 to 6 weeks following surgery. Nurse Kim should convey to Robert that it's normal to expect limitations in hand movements for approximately 4 to 6 weeks following carpal tunnel release surgery. This period allows for healing and gradual return to normal activities. During this time, the patient may experience varying degrees of discomfort, swelling, and stiffness, and it's important for them to understand that these are part of the normal healing process. Patients are often advised to gradually increase their hand and wrist activities under the guidance of a healthcare professional, usually as part of a rehabilitation program.

Think of the surgery as repair work done on a frequently used tool (the hand). Just like you'd avoid putting too much strain on a tool right after it's been fixed to ensure the repair holds well, the hand needs a careful, gradual return to normal use to ensure proper healing and to avoid complications.

After carpal tunnel release surgery, the tissues around the transverse carpal ligament and median nerve need time to heal. As healing progresses, scar tissue forms, which can be less flexible than the original tissue, leading to temporary stiffness and limitations in movement. Physical therapy and gradual use of the hand can help in regaining strength and flexibility, but it's important for patients to understand that this process takes time, typically 4 to 6 weeks, but sometimes longer.

 

✘Incorrect answer options:

Contact the physician immediately if you experience any level of pain or discomfort. While patients should be advised to monitor their pain levels and contact their physician if they experience severe or worsening pain, experiencing some level of pain or discomfort post-surgery can be normal. The key is to provide guidance on what levels of pain are expected and what signs should prompt a call to the physician.

You won't need frequent dosages of pain medication post-discharge. This statement is too generalized and might not apply to every patient. Pain experiences and medication needs can vary, and it's important for patients to have clear guidance on managing pain, including when and how to take any prescribed pain medications.

The surgical procedure should be considered a definitive cure for carpal tunnel syndrome. While carpal tunnel release surgery is generally effective, it's not guaranteed to be a definitive cure for every patient. Some patients may continue to experience symptoms or may have recurrences, especially if underlying factors contributing to the condition, such as repetitive hand motions or certain health conditions, are not addressed.

 

References

• Keith, M. W., Masear, V., Amadio, P. C., Andary, M., Barth, R. W., Graham, B., ... & Watters, W. C. (2009). Treatment of carpal tunnel syndrome. The Journal of the American Academy of Orthopaedic Surgeons, 17(6), 397-405.
• American Society for Surgery of the Hand. (n.d.). Carpal Tunnel Release. Retrieved from [source].

EXPLANATION

 

✔Correct answer:

Administers a dose of 600 mg of ibuprofen to the patient. The action that would necessitate immediate intervention is administering a dose of 600 mg of ibuprofen to the patient. While LPNs/LVNs are trained and authorized to administer medications, the concern here is specific to the patient's condition—Paget's disease. Patients with Paget's disease often have an increased blood supply to their bones, which can increase the risk of bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can further increase this risk by inhibiting platelet function and increasing the likelihood of gastrointestinal bleeding. This risk may be compounded in elderly patients who may have additional risk factors for NSAID-related complications. Therefore, it's crucial to closely monitor the medication regimen of a patient with Paget's disease and ensure it's aligned with their specific health needs and risks.

Imagine the patient's condition (Paget's disease) as a garden that's being watered too much (increased blood supply to the bones). Using a medication like ibuprofen is akin to using a tool (medication) that might accidentally poke holes in the garden's hose (blood vessels), leading to water (blood) leaking out where it's not supposed to. In this scenario, you want to be very careful about the tools you use in the garden to avoid causing unnecessary damage.

Paget's disease involves the abnormal breakdown and formation of bone tissue, leading to bones that are enlarged and weakened. This process often results in an increased blood supply to the affected bones. NSAIDs, such as ibuprofen, can inhibit platelet aggregation and compromise the integrity of the gastrointestinal lining, increasing the risk of bleeding. In the context of Paget's disease, where there's already an increased blood supply to the bones, the use of NSAIDs might pose an elevated risk for bleeding, both at the site of the bone lesion and potentially in the gastrointestinal tract.

 

✘Incorrect answer options:

Suggests the patient to consume milk and cottage cheese for calcium intake. This is an appropriate nutritional intervention to ensure adequate calcium intake, which is important for bone health, especially in patients with Paget's disease.

Motivates the patient to complete physical therapy-recommended exercises. Encouraging the patient to stay active and follow physical therapy recommendations is appropriate and beneficial for maintaining mobility and strength, particularly in patients with Paget's disease.

Applies cold packs and performs gentle massage on the patient's lower extremities. Cold packs and gentle massage can be part of symptomatic treatment for pain and discomfort associated with Paget's disease, as long as there are no contraindications for their use on the patient.

 

References

• Siris, E. S., & Roodman, G. D. (2005). Paget's Disease of Bone. In J. P. Bilezikian, L. G. Raisz, & G. A. Rodan (Eds.), Principles of Bone Biology (3rd ed., pp. 1285-1298). Academic Press.
• Roodman, G. D. (1996). Pathogenesis of Paget's Disease of Bone. Bone, 19(5), 573-578.

EXPLANATION

 

✔Correct answer:

A 72-year-old patient diagnosed with Paget’s disease, who has just come back from a total knee replacement surgery. Assigning the nurse from the Post-Anesthesia Care Unit (PACU) to care for the 72-year-old patient who has just returned from a total knee replacement surgery would be the most appropriate decision. PACU nurses are specialized in providing care for patients recovering from anesthesia following surgery. They have the expertise in monitoring patients' vital signs, managing pain, assessing level of consciousness, and ensuring safe recovery immediately after surgery. The skills required for postoperative care, particularly after a major surgery like total knee replacement, align closely with the experience and training of a PACU nurse.

Think of the PACU nurse as a specialist in post-surgery recovery, much like a pit crew in a car race that is specialized in getting the race car (patient) back on track after a pit stop (surgery). Just as the pit crew uses its specialized skills to ensure the car is ready to race safely and effectively, the PACU nurse uses their specialized skills to ensure the patient safely recovers from the effects of anesthesia and surgery.

After a total knee replacement surgery, it's crucial to monitor the patient for signs of complications, manage pain, and ensure the patient's safe recovery. PACU nurses are adept in early identification of issues such as bleeding, infection, or adverse reactions to anesthesia. Their skills are essential in the initial postoperative period, where close monitoring and expert care can significantly impact the patient's recovery trajectory.

 

✘Incorrect answer options:

A 62-year-old patient diagnosed with osteomalacia, set to be discharged to a long-term care facility. This patient likely requires discharge planning and coordination of care, which might not align with the PACU nurse's specialized skills.

A 35-year-old patient suffering from osteomyelitis, who requires educational guidance prior to undergoing hyperbaric oxygen therapy. This situation involves patient education and preparation for a specific therapy, which might be better suited for a nurse with experience in infectious diseases or wound care.

A 68-year-old patient with osteoporosis, recently fitted with a new orthotic device, requiring an assessment of their understanding of its use. This patient requires education and assessment of understanding regarding the use of a new orthotic device, which might be better suited for a nurse with experience in orthopedics or rehabilitation.

 

References

• Drain, C. P. (2003). Perianesthesia Nursing: A Critical Care Approach (5th ed.). Saunders.
• Odom-Forren, J. (2019). Drain's PeriAnesthesia Nursing: A Critical Care Approach (7th ed.). Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

A body temperature of 99.9°F. Osteomyelitis is an infection of the bone, and a key indicator of infection is an elevated body temperature or fever. While a temperature of 99.9°F is not extremely high, it is above the normal range and could indicate that the patient's infection is not well-controlled or is worsening. In the context of osteomyelitis, it's crucial to monitor for signs of systemic infection, and fever is a primary symptom. Therefore, you would instruct the nursing assistant to report a body temperature of 99.9°F immediately, as it may necessitate further assessment, intervention, or modification of the treatment plan.

Think of the body like a security system, and the fever (elevated temperature) is like an alarm. Just as the alarm goes off when there's a possible intruder (infection), the body's temperature rises when there's an infection. Just as you would want to be informed immediately if the security alarm goes off, you'd want to know right away if the patient has a fever, so you can address the underlying cause.

Fever is a common and natural response to infection and is part of the body's defense mechanism. It occurs because the body's thermostat (regulated by the hypothalamus) resets to a higher temperature in response to an infection. This increase in body temperature can help the body fight off the infectious agents more effectively. In the case of osteomyelitis, monitoring temperature is crucial because it can provide early indication of an acute infection or exacerbation of a chronic infection, necessitating prompt medical attention.

 

✘Incorrect answer options:

A heart rate of 96 beats per minute. While slightly elevated, this heart rate is not typically alarming and can be within normal limits, especially if the patient is in pain, anxious, or has just been physically active.

A respiratory rate of 24 breaths per minute. This is at the higher end of the normal range (12-20 breaths per minute for adults) and could be due to various factors including fever, pain, or anxiety, but on its own, it is not as immediately concerning as a fever in a patient with osteomyelitis.

A blood pressure reading of 136/80 mm Hg. This blood pressure reading is slightly high but falls within the prehypertension range. It does not typically represent an immediate concern unless the patient has a history of hypertension or other related health issues.

 

References

• Mader, S. S., & Windelspecht, M. (2019). Human Biology (16th ed.). McGraw-Hill Education.
• Lewis, S. M., Heitkemper, M. M., Bucher, L., Harding, M., Kwong, J., & Roberts, D. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

A 28-year-old patient with a cast due to a fracture, expressing that the cast feels too tight. Nurse Emily should prioritize assessing the 28-year-old patient with a cast due to a fracture who is expressing that the cast feels too tight. This could be indicative of compartment syndrome, a serious condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, preventing nourishment and oxygen from reaching nerve and muscle cells. Compartment syndrome is a medical emergency requiring immediate intervention to prevent tissue damage, loss of limb function, or even amputation.

Imagine the muscles and nerves inside the cast as a group of people in a room. If the room becomes too crowded (the cast is too tight), people (muscles and nerves) can't get enough air (blood supply) and might start to get sick (damaged). Just like you'd want to open a door or window (relieve the pressure) to let air in and make everyone comfortable, the pressure under the cast needs to be relieved to ensure proper blood flow and prevent damage.

A cast that is too tight can compress nerves, blood vessels, and muscles. This can lead to decreased blood flow (ischemia) and can cause nerve damage and muscle death if not addressed promptly. The classic signs of compartment syndrome include pain that is not proportional to the injury, pain on passive stretch of muscles within the compartment, paresthesia (tingling or burning sensation), pallor, paralysis, and pulselessness (the latter two are late signs).

 

✘Incorrect answer options:

A 42-year-old patient diagnosed with carpal tunnel syndrome, complaining of persistent pain. While pain management is important, this situation is not typically as urgent as a patient with a potential compartment syndrome.

A 56-year-old patient who underwent a left leg amputation and is experiencing phantom pain. Phantom limb pain is a common occurrence after amputation. While distressing, it is not an immediate physiological threat as compared to compartment syndrome.

A 64-year-old patient with osteoporosis, prepared for discharge and awaiting final paperwork. This patient's needs are administrative and do not present an immediate risk to their health or safety.

 

References

• Von Keudell, A., Weaver, M. J., Appleton, P. T., Bae, D. S., Dyer, G. S., Heng, M., ... & Harris, M. B. (2015). Diagnosis and treatment of acute extremity compartment syndrome. The Lancet, 386(10000), 1299-1310.
• McQueen, M. M., & Duckworth, A. D. (2019). Diagnosis of acute compartment syndrome. Journal of Bone and Joint Surgery. American Volume, 101(7), 623-628.

EXPLANATION

 

✔Correct answer:

"I will call Nurse Emma to come and discuss this matter with you." The most appropriate guidance Nurse Emma should give to the nursing assistant is to offer to call Nurse Emma (or another qualified healthcare professional) to discuss the matter with the patient. This approach acknowledges the patient's curiosity and need for information while ensuring that the information provided is accurate and comes from a healthcare professional with the appropriate knowledge and experience to discuss prostheses. This response shows respect for the patient's concerns and ensures that they receive reliable and comprehensive information appropriate to their stage of recovery and individual needs.

Imagine you're at a restaurant and have a question about a specific dish's ingredients because you have allergies. The best approach for the waiter would be to say, "Let me get the chef to answer that for you," ensuring you get accurate information from the right source. Similarly, the nursing assistant should refer the patient's question about prostheses to the nurse or another qualified healthcare professional to provide the most accurate and helpful information.

After a below-the-knee amputation, a patient's recovery process involves not just physical healing but also psychological adjustment and planning for rehabilitation, which may include the use of a prosthesis. Discussing prosthetic options involves considering various factors, including the level of amputation, the patient's physical condition, lifestyle, goals, and the healing of the residual limb. It's important that such discussions are guided by healthcare professionals who can provide comprehensive information and support to the patient.

 

✘Incorrect answer options:

"It's crucial for you to get a prosthesis so you can walk again." This statement is too definitive and may not take into account the patient's individual condition, preferences, or the timing for a prosthesis fitting.

 "Hold that question for your doctor during his next visit." While it's important for the patient to discuss this with their doctor, this response might make the patient feel that their curiosity is not valued or that their needs are being postponed.

"You shouldn't be concerned about a prosthesis this early." This response may dismiss the patient's feelings and concerns. It's important for patients to feel that their healthcare team is supportive and willing to discuss future steps at any stage of recovery.

 

References

• Gailey, R. S., Roach, K. E., Applegate, E. B., Cho, B., Cunniffe, B., Licht, S., ... & Linberg, A. A. (2002). The amputee mobility predictor: an instrument to assess determinants of the lower-limb amputee's ability to ambulate. Archives of physical medicine and rehabilitation, 83(5), 613-627.
• Highsmith, M. J., Kahle, J. T., Bongiorni, D. R., Sutton, B. S., Groer, S., & Kaufman, K. R. (2010). Safety, energy efficiency, and cost efficacy of the C-Leg for patients with transfemoral amputation: a review of the literature. Prosthetics and orthotics international, 34(4), 362-377.

EXPLANATION

 

✔Correct answer:

The base of the patient's skull appears to be invaginated, also known as platybasia. Platybasia, or the invagination (inward deformation) of the base of the skull, in a patient with Paget's disease is an alarming sign that should prompt immediate notification of the physician. Platybasia can lead to serious complications such as basilar invagination, where the top of the spine pushes into the base of the skull. This can put pressure on the brainstem, spinal cord, and cranial nerves, leading to neurological symptoms and potentially life-threatening complications. Immediate medical evaluation is necessary to assess the extent of skull involvement and to manage any complications effectively.

Think of the skull as the foundation of a house and the brain as the house's delicate interior. If the foundation starts to cave in (platybasia), it can put pressure on the interior, damaging the structure and the contents inside. Just like you'd immediately call for help if your house's foundation was compromised, it's crucial to notify the physician right away if the base of the skull is invaginated, to protect the brain and other vital structures.

In Paget's disease, there is abnormal and excessive bone remodeling. The new bone that is formed is larger but weaker and softer than normal bone, which can lead to structural deformities. Platybasia in the context of Paget's disease indicates that the disease has affected the skull, potentially compromising the structural integrity of the base of the skull. This can lead to neurological complications due to the proximity to the brainstem and cranial nerves.

 

✘Incorrect answer options:

The patient has a height of 5 feet and weighs 120 pounds. This is a normal finding and does not indicate an immediate need for concern or notification of the physician.

The patient exhibits bowing in both legs and asymmetrical knees. While bowing of the legs and asymmetrical knees can be associated with Paget's disease and may require management, they are not typically urgent issues that require immediate notification of the physician.

The patient's skull feels soft to the touch, is noticeably thickened, and has an enlarged appearance. These findings are consistent with Paget's disease affecting the skull but are not as immediately concerning as the potential neurological implications of platybasia. However, these symptoms should still be closely monitored and managed appropriately.

 

References

• Singer, F. R., Bone, H. G., III, & Hosking, D. J. (1995). Paget's Disease of Bone: Clinical Assessment, Present, and Future Therapy. Journal of Bone and Mineral Research, 10(8), 1177-1181.
• Roodman, G. D., & Windle, J. J. (2005). Paget Disease of Bone. Journal of Clinical Investigation, 115(2), 200-208.

EXPLANATION

 

✔Correct answer:

She encourages the patient to transition directly from a lying to a standing position. Encouraging the patient to transition directly from a lying to a standing position would require immediate intervention. For a patient with a fractured right ankle and impaired physical mobility, moving directly from lying down to standing up can be unsafe and may increase the risk of falls or further injury. It's important for patients to make gradual transitions in position, usually moving from lying to sitting, and then from sitting to standing, allowing time for the body to adjust and ensuring stability before bearing weight on the injured limb, especially when the patient is recovering from a fracture and may have balance issues or weakness.

Imagine the patient's body as a car on a steep hill with a manual transmission. Just like you would slowly and carefully shift gears to get the car moving safely without it rolling back down the hill, the patient needs to move through positions gradually to ensure stability and safety, especially with a fractured ankle.

When a patient has a lower limb fracture and has been lying down for a period, blood pressure and muscle strength may not be optimized for immediate weight-bearing and balance. Orthostatic hypotension (a sudden drop in blood pressure upon standing) can occur if the patient stands up too quickly, leading to dizziness or fainting. Moreover, the muscles may need a gradual transition to properly support the body's weight, especially when one limb is compromised due to a fracture.

 

✘Incorrect answer options:

She administers pain medication before initiating any exercises. Administering pain medication before exercises is appropriate as it can help manage pain, making it more comfortable for the patient to participate in necessary mobility exercises.

She takes time to remind the patient about the proper use of crutches. Educating and reminding the patient about the proper use of assistive devices like crutches is important for safe mobility and prevention of falls or further injury.

She educates both the patient and their family about the importance of the exercise regimen. Patient and family education about the exercise regimen is crucial for understanding the treatment plan, ensuring compliance, and facilitating recovery.

 

References

• Perry, A. G., Potter, P. A., & Ostendorf, W. (2018). Clinical Nursing Skills and Techniques (9th ed.). Elsevier.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (9th ed.). Elsevier.

EXPLANATION

 

✔Correct answer:

The weights for the traction are touching the floor. The nursing assistant should promptly report if the weights for the traction are touching the floor. Skeletal traction involves the use of weights to align and stabilize a fractured bone, and for it to be effective, the weights must hang freely. If the weights are touching the floor, it indicates that the traction system is not functioning as intended, which could lead to inadequate fracture alignment, delayed healing, or further injury. Immediate intervention is required to readjust the traction setup and ensure it is correctly positioned to provide the necessary pull for proper bone healing.

Imagine skeletal traction like a pulley system used to keep a heavy door (the fractured bone) aligned and closed (healing properly). The weights (traction weights) need to hang freely for the door to stay in the right position. If the weights touch the ground, the door might move out of place (the bone might not heal correctly). So, it's important that the weights are hanging as they should, to keep everything aligned.

In skeletal traction, weights apply a constant force to align and stabilize long bone fractures, like those of the fibula. The steady pull of the weights counteracts muscle spasms and helps to align the bone fragments properly. This constant and correct force is crucial for the fractured bone to heal in the correct position. If the weights are not hanging freely, the necessary force is not applied correctly, potentially compromising the healing process.

 

✘Incorrect answer options:

A slight amount of clear fluid is noted around the pin sites. A small amount of clear fluid drainage around pin sites can be normal. However, any changes in the amount, color, or odor of the drainage should be monitored as they may indicate an infection.

The patient is expressing discomfort and experiencing muscle spasms. While discomfort and muscle spasms are important to address, they are not as immediately concerning as the malfunctioning of a traction system. Muscle spasms can be a common occurrence with fractures and traction.

The patient is requesting to adjust his position in bed. It's normal for patients to want to adjust their position for comfort. This request should be addressed, but it's not as urgent as ensuring the proper function of the traction system.

 

References

• Egol, K. A., Koval, K. J., & Zuckerman, J. D. (2015). Handbook of Fractures (5th ed.). Wolters Kluwer.
• Stannard, J. P., Schmidt, A. H., & Kregor, P. J. (2016). Surgical Treatment of Orthopaedic Trauma (2nd ed.). Thieme.

EXPLANATION

 

✔Correct answer:

It's natural to experience a few bumps and bruises upon returning home. The statement "It's natural to experience a few bumps and bruises upon returning home" should not be included in the educational session for a patient with osteoporosis. This statement might inadvertently minimize the seriousness of falls and injuries, which can be particularly severe for someone with osteoporosis. Patients with osteoporosis are at a higher risk of fractures even from minor falls or bumps due to the decreased density and strength of their bones. Therefore, it is crucial to emphasize the importance of preventing falls and injuries rather than suggesting that minor injuries are to be expected or are a natural part of life.

Imagine the bones as a fragile glass sculpture. For someone with strong, healthy bones, a small bump might not cause any damage. But for someone with osteoporosis, even a minor bump can lead to significant damage, just like a fragile sculpture can easily break or chip if not handled with care. It's important to avoid any scenarios that could lead to even minor accidents.

Osteoporosis is a condition characterized by weakened bones, which makes them more susceptible to fractures. Even minor falls or traumas can lead to serious bone injuries in individuals with osteoporosis. Educating patients about fall prevention is crucial because preventing falls is one of the most effective ways to prevent fractures and other serious injuries in individuals with osteoporosis.

 

✘Incorrect answer options:

Eliminate any throw rugs and potential tripping hazards in your home. This is an appropriate point to include in the teaching. Removing tripping hazards is a key step in minimizing the risk of falls.

Engaging in exercise can help in strengthening your muscles. This is also an appropriate point. Regular, appropriate exercise can help strengthen muscles and improve balance, reducing the risk of falls.

Make sure to rest when you start to feel fatigued. This is a valid point to include in the teaching. Fatigue can increase the risk of falls, so it's important for individuals to listen to their bodies and rest as needed to maintain safety.

 

References

• Cosman, F., de Beur, S. J., LeBoff, M. S., Lewiecki, E. M., Tanner, B., Randall, S., & Lindsay, R. (2014). Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporosis International, 25(10), 2359-2381.
• National Osteoporosis Foundation. (2020). Preventing Fractures. [online] Available at: [URL] (Accessed 20 April 2023).