Medical-Surgical B(Week 1: Ch.65 Arthritis and Connective Tissue Diseases p.1641 Week 2: Ch.63 Musculoskeletal Trauma and Orthopedic Surgery p.1583 Week 7: Ch.57 Acute Intracranial Problems Week 3: Ch.17 Fluid, Electrolyte and Acid-Base Imbalances; Ch.26

Rank in order the sequence of events leading to joint destruction in secondary osteoarthritis (OA) beginning with the effect of an injury to the cervical spine. A. Exacerbation of abdominal tissue growth B. Bony articular surfaces in joint exposed C. Fragile, soft, dull joint cartilage develops D. Irregular joint motion, stiffness, and pain C. Fragile, soft, dull joint cartilage develops A. Exacerbation of abdominal tissue growth D. Irregular joint motion, stiffness, and pain B. Bony articular surfaces in joint exposed A precipitating factor, such as trauma to the spine, leads to the development of OA by damaging the cartilage. Joint destruction begins with the development of dull, soft, less elastic, and more fragile cartilage. Because the body is unable to repair the cartilage fast enough, the cartilage develops fissures and erosion and, in so doing, becomes thinner, leading to the formation of osteophytes and cartilage at the joint margins. The formation of abnormal tissue leads to abnormal joint movement. Pain and stiffness increase as the bony surfaces of the joint are exposed. Ch. 65 Pre-Assessment #1 The nurse is assessing a patient who is complaining of joint pain and stiffness. Which assessment does not differentiate between osteoarthritis (OA) and rheumatoid arthritis (RA)? A. Symmetry of joint effect B. Duration of joint stiffness C. Space between the bones D. Erythrocyte sedimentation rate C. Space between the bones Both OA and RA manifest with narrowed joint spaces so this is not a valid assessment to help differentiate between the two disorders. The remaining options are patient assessments that facilitate differentiation of OA and RA because symmetric joints are affected in RA but not in OA; stiffness resolves in less than 30 minutes with OA but not RA; and a patient with RA, but not OA, is likely to have elevated erythrocyte sedimentation levels indicating inflammation. Ch. 65 Pre-Assessment #2 00:59 01:21 A 75-year-old female patient complains about morning stiffness and increasing joint pain in her right hip. What is the best initial drug therapy for her? A. aspirin B. naproxen (Aleve) C. ibuprofen (Motrin) D. acetaminophen (Tylenol) D. acetaminophen (Tylenol) For patients with osteoarthritis who have mild to moderate pain, the initial drug of choice is acetaminophen. Ch. 65 Pre-Assessment #3 Which of the following laboratory values would probably be found in a patient with osteoarthritis (OA)? A. Decreased RBCs B. Increased WBCs C. Clear yellow synovial fluid D. Increased C-reactive protein E. Increased erythrocyte sedimentation rate C. Clear yellow synovial fluid Normally there are no laboratory abnormalities or biomarkers for OA. Clear yellow fluid is normal synovial fluid. Ch. 65 Pre-Assessment #4 A patient who has ankylosing spondylitis (AS) asks the nurse for help in choosing suitable activities for maintaining good posture. Which exercise should the nurse advise the patient to avoid? A. Do stomach crunching B. Stand on a single leg C. Face wall and push off D. Stretch the lower back A. Do stomach crunching The nurse advises a patient who has AS to avoid stomach crunches because they involve spinal flexion, which over the long term can aggravate pulmonary complications by decreasing the thoracic cage. The help strengthen the same muscles, the nurse encourages exercises to strengthen the upper and lower back such as leg lifts in the prone position because in the prone position the back is supported to prevent flexion. The remaining options can be suitable exercises for this patient, standing on one leg promotes core strength, pushing off a wall strengthens back muscles, and stretching the lower back helps maintain joint flexibility. Ch. 65 Pre-Assessment #5 The incidence of Lyme disease is very high in a Pennsylvania county, so the public health nurse provides community education to increase the number of patients who seek health care promptly after a tick bite. Which information should the nurse provide in community teaching people who are at risk for a tick bite? A. The best therapy for the acute illness is an IV antibiotic. B. Check for an enlarging reddened area with a clear center. C. Antibiotics will prevent Lyme disease if taken for 10 days. D. Surveillance is necessary during the summer months only. B. Check for an enlarging reddened area with a clear center. Following a tick bite, individuals should mark the area with a pen and watch for a reddened lesion that enlarges within 2 to 30 days after the bite, develops a clear center, has a bright red border, and is accompanied by flu-like symptoms and migrating joint and muscle pain. When Lyme disease is confirmed, oral doxycycline (Vibramycin) can be effective if started within 3 days of the bite, and 2 to 3 weeks of antibiotic therapy is usually effective. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. Ch. 65 Pre-Assessment #6 In comparing connective tissue disorders, which disorder is most likely to result in patient injury, affect pulmonary function, and increase the patient's risk of infection as a result of the indicated drug therapy? A. Polymyositis (PN) B. Sjogren's Syndrome (SS) C. Systemic sclerosis (scleroderma) D. Systemic lupus erythematousus (SLE) A. Polymyositis (PN) PN is an inflammatory disease of striated muscle, resulting in muscle weakness that increases the patient's risk of falls and injury. In addition, most patients with PN develop interstitial lung disease, which can impair pulmonary function. The risk of infection increases during therapy with corticosteroids because these drugs suppress the immune response to potential pathogens. Ch. 65 Pre-Assessment #7 Patients who have which of this following connective disorders are least likely to experience significant pain because of the primary pathophysiologic process of this disorder? A. FIbromyalgia B. Lyme disease C. Sjogren's syndrome (SS) D. Systemic lupus erythematousus (SLE) C. Sjogren's syndrome (SS) Patients who have SS are least likely to require pain management from the pathophysiologic result of the disorder because the result is dryness. Fibromyalgia causes generalized musculoskeletal, nonarticular pain. Lyme disease is characterized my migrating joint pain, and SLE can result in polyarthalgia. Ch. 65 Pre-Assessment #8 A patient who is receiving methotrexate for lung cancer has a serum uric acid of 8 mg/dL and develops excruciating pain in the great toe. What should be used to minimize the effects of the patient's metabolic problem and prevent nephrotoxicity? A. IV fluids B. colchicine C. naproxen (Naprosyn) D. probenecid (Benemid) A. IV fluids Administering IV fluids to a patient who has hyperuricemia from chemotherapy dilutes the serum concentration of uric acid, helps prevent uric acid crystal formation, and helps preserve renal function. This is a very important goal for the nurse because methotrexate can cause renal dysfunction. Ch. 65 Pre-Assessment #9 The home care nurse visits an elderly patient diagnosed with Parkinson's disease who fell while ambulating. What observation is of most concern to the nurse? A. Stooped posture with a shuffling gait and slow movements. B. 2 × 6 cm contusion located on the right thigh C. Left leg externally rotated and shorter than the right leg. D. Mild pain and minimal swelling of the right ankle and foot. C. Left leg externally rotated and shorter than the right leg. Rationale: Clinical manifestations of a hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. A contusion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain. Evolve Ch. 63 #1 A patient with a fracture of the proximal left tibia in a long leg cast complains of severe pain distal to the fracture site and paresthesia. The toes on the left foot are pale and cool. Which action should the nurse take? A. Elevate the left leg above the level of the heart. B. Administer prescribed morphine sulfate intravenously. C. Notify the health care provider immediately. D. Apply ice packs to the left proximal tibia over the cast. C. Notify the health care provider immediately. Rationale: Clinical manifestations of compartment syndrome include paresthesia; pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment; pressure increases in the compartment; pallor, coolness, and loss of normal color of the extremity; paralysis or loss of function; and pulselessness or diminished/absent peripheral pulses. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. Notify the health care provider immediately of a patient's changing condition. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Evolve Ch. 63 #2 The nurse performs discharge teaching for a patient after a left hip arthroplasty (posterior approach). Which statement, if made by the patient to the nurse, indicates teaching is successful? A. "Driving a car should not be attempted for 2 to 3 weeks." B. "Leg raising exercises will need to be done for several months." C. "My blood will be tested while taking enoxaparin (Lovenox)." D. "There will not be any restrictions on hip and leg movements." B. "Leg raising exercises will need to be done for several months." Rationale: Exercises designed to restore strength and muscle tone will be done for months after surgery; the exercises will include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart; the patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status. Evolve Ch. 63 #3