CHAPTER 27

Musculoskeletal Care

Part 1. Key Terms Review

Match the following Key Term(s) or italicized words from your text with the correct
description.
_____   1. Osteoarthritis
_____   2. External fixator
_____   3. Sprain
_____   4. Prosthesis
_____   5. Fractures
_____   6. Spica
_____   7. Amputate
a. An injury to joints that results in damage to muscles
and ligaments
b. The type of cast that encases the hips and one or both
legs
c. An artificial body part, such as an arm or a leg
d. A disease that causes degeneration and inflammation
of the joints over time
e. Surgical removal of a limb as a result of extensive
trauma or tissue death
f. The head of the femur and the acetabulum of the pelvis
g. Wires, pins, tongs, or rods used in skeletal traction
h. Breaks in the bone, ranging from a narrow crack to
many pieces

Fill in the blank with the correct Key Term(s) or italicized words from your text.
8. A surgery in which damaged articular bone surfaces are removed and replaced with metal
and plastic surfaces is called a _________________.
9. The term _________________ refers to the remaining portion of a limb after an amputation.
10. The health-care team member responsible for assessing musculoskeletal disorders and
developing the plan of care to strengthen muscles and restore mobility is _______________.
11. The machine used to gently flex and extend the patient’s knee after a total knee replacement
is a _________________ machine.
12. The type of traction in which the limb is wrapped in an elastic bandage or wrap to which a
frame and weights are attached is _________________ traction.
13. The type of traction in which external fixators are used is referred to as
_____________________________ traction.

Part 2. Connection Questions

Choose the correct answer(s). In some questions, more than one answer is correct. Select all
that apply.
14. When you care for a patient prior to surgery, one of your primary concerns is
a. Researching the exact surgery that will take place.
b. Ensuring that all preoperative orders are carried out correctly.
c. Showing the family where to wait during the surgery.
d. Explaining the surgical techniques that will be used with the patient.
15. When you care for a patient after a partial or total joint replacement, a major nursing focus
will be
a. Teaching the patient about healthy lifestyles.
b. Screening the family for joint diseases.
c. Managing pain and mobility.
d. Preventing complications related to immobility.
16. A patient came to the ER complaining of pain in her elbow after a fall. The x-ray shows
fractured ulna at the olecranon process. There is also a suspected fracture of the radius.
Which diagnostic test would be most helpful in determining a complete diagnosis?
a. CT scan
b. MRI
c. Bone scan
d. Electromyelogram
17. A 10-year-old has a fractured left leg with no trauma occurring to cause it. The health-care
provider diagnoses a pathological fracture, possibly from a bone tumor. What type of
diagnostic test would be ordered in this situation?
a. CT scan
b. MRI
c. Bone scan
d. Electromyelogram
18. The components of the hip joint that form the ball and socket are the
a. Pelvis and greater trochanter.
b. Femur and patella.
c. Acetabulum and lesser trochanter.
d. Head of the femur and the acetabulum.
19. You are working in a home health setting. Which of the following assessments would cause
you to consider asking your supervisor to arrange for a physical therapy referral for your
patient?
a. The patient is ambulating in the home with a walker.
b. The patient had surgery recently and is holding on to furniture to ambulate.
c. The patient uses a wheelchair in the home, which has been remodeled to accommodate it.
d. The patient is able to transfer with the assistance of one person and has a 24-hour caregiver
in the home.
20. You are working in a long-term care setting. One of the residents is able to ambulate but sits
in a wheelchair each day. What action will you take?
a. Check the orders for ambulation and be sure that they are followed to promote mobility.
b. Change the activity order to wheelchair only because the resident prefers to sit rather than
ambulate.
 c. Instruct the CNA to do passive range-of-motion exercises because the resident is not
ambulating anymore.
d. Call the doctor and report that the resident is no longer ambulating.

Write brief answers to the following questions.

21. Explain the purpose of an abduction pillow.

22. Fill in the acronym for the care of a sprain.

R = _____
I = _____
C = _____
E = _____

Part 3. Review Questions

Choose the correct answer(s). In some questions, more than one answer is correct. Select all
that apply.
23. A common condition that requires a joint replacement is
a. A hairline fracture.
b. Osteoarthritis.
c. A comminuted fracture.
d. An amputation.
24. The reason(s) that a limb might have to be amputated include
a. Severe tissue damage from trauma.
b. Severely decreased blood flow to the limb.
c. Failure of skeletal traction to successfully treat a fracture.
d. Gangrene (death of tissue) in the limb.
e. Cancerous tumor of the bone.
25. A typical ambulation order by a health-care provider or physical therapist might be
a. “Walk patient in hall.”
b. “Ambulate in hall several times.”
c. “Ambulate 24 steps each day.”
d. “Ambulate three times per day, 20 feet (6 meters) each time.”
26. Who is responsible for carrying out ambulation orders for patients?
a. PT only
b. Nursing assistants only
c. All nursing staff and PT staff
d. PT assistants only
27. A type of external fixator composed of metal rings on the outside of the limb with rods and
wires attached that penetrate through the skin into the bone is a(n)
a. External immobilizer.
b. Buck’s traction setup.
 c. Skin traction setup.
d. Ilizarov frame.
28. You are caring for a young child with hip dysplasia who is in a spica cast. An important
nursing concern is
a. Assessing circulation to the fingers and hands.
b. Moving the patient carefully without using the abductor bar.
c. Keeping the patient’s hips elevated above the heart.
d. Aligning the hips each time the patient is turned.
29. A patient is admitted with an elevated temperature and complaining of pain under his arm
cast. A bad odor is noted coming from the elbow area of the cast. The patient tells you that
his arm has been itching a great deal under the cast. What concern do you have?
a. The patient may have damaged the skin under the cast, causing infection.
b. The bone is not healing well under the cast, causing the pain.
c. The skin under the cast is breaking down because of pressure from the cast.
d. The patient may be developing gangrene (tissue death) under the cast, causing the odor.
30. What patient teaching will you do for the patient described in Question 29?
a. Teach the patient to use a straightened coat hanger padded with gauze to scratch under the
cast.
b. Instruct the patient to use a blow dryer to blow cool air under the cast to relieve itching.
c. Explain how epidermal cells shed, then build up under the cast, causing itching.
d. Suggest that the patient blow hot air under the cast with a blow dryer to relieve itching.
31. A patient has a quarter-size amount of drainage on her cast. The next day the amount of
drainage has increased to 2 inches (5 cm) in diameter. The nurse would be most concerned
about
a. Swelling beneath the cast.
b. Neurovascular impairment.
c. Infection under the cast.
d. Placing tape petals over the edges of the cast.
32. The purpose of a trapeze bar is to
a. Prop the linens off of the patient’s legs and feet.
b. Hold the ropes and weights in traction.
c. Provide a hand grip for the patient to use when moving in bed.
d. Provide attachment points for skeletal traction.
33. Which would you consider to be significant findings when caring for a patient with skeletal
traction?
a. Redness and swelling at the pin insertion sites
b. A small amount of serosanguineous drainage at the pin insertion sites
c. Purulent drainage at the pin insertion sites
d. Mild discomfort when the patient moves the limb in traction
34. Care of the pin insertion sites includes
a. Cleaning the area with hydrogen peroxide or normal saline solution as ordered.
b. Applying antibiotic ointment to the site.
c. Inspecting the site for signs and symptoms of infection.
 d. Shaving the hair around the site.
35. Which bone components are replaced in a total hip replacement surgery?
a. The head and neck of the femur and the acetabular cup
b. The greater trochanter of the femur and the acetabular cup
c. The ilium and the head of the femur
d. The distal end of the femur and the head of the tibia
36. A patient who is 3 days post left total hip replacement with the lateral approach is sitting in a
chair and drops a magazine. How should he or she retrieve it?
a. Bend laterally at the waist to pick it up.
b. Bend over with the knees flexed to pick it up.
c. Call for someone else to pick it up.
d. Use an extension gripper to pick it up.
37. What are the articular surfaces in a total knee replacement?
a. A metal tibial component that articulates with the plastic surface of the femoral component
b. A metal femoral component that articulates with the plastic fibula component
c. The patella is replaced with plastic or similar substance or has plastic affixed to the back to
provide a smooth articular surface
d. The patella, tibia, and femur are replaced with plastic or polyethylene components
38. What is the purpose of wrapping a stump after an amputation?
a. To shape it to fit correctly into the prosthesis
b. To prevent healing in a squared-off shape
c. To prevent the incision from breaking open while wearing a prosthesis
d. To promote healing of the incision
39. You know a patient’s crutches fit correctly when
a. There is a three-fingerbreadth gap of space between the axillary pad and the patient’s
axilla.
b. There is a slight bend in the patient’s elbows when standing with the crutches next to his
or her feet.
c. The crutches fit snugly into the axilla when the patient is standing with the crutch tips next
to the heels.
d. There is a 6-inch or larger gap between the patient’s axilla and the top of the crutch.
40. A patient states he has fallen twice since using crutches for a foot injury. Which of the
following questions might you want to ask him?
a. “Have you had any physical therapy for balancing exercises?”
b. “Are you sure your crutch tips are not too slick?”
c. “Would you show me how you hold your foot when you walk with the crutches?”
d. “Haven’t you ever used crutches before?”
41. What is the advantage of a multipronged cane over a single-tipped cane?
a. It is easier to adjust to the patient’s height.
b. It can stand by itself rather than having to be leaned against something.
c. The handle on a multipronged cane is easier to grasp.
d. It decreases the chances of the cane slipping as the patient leans on it.
42. Which of the following would you include when you teach a patient about using a cane?
 a. Hold the cane on your affected side.
b. Move the unaffected leg and the cane together, and then move the affected leg.
c. Lean to the side the cane is on for best support.
d. All of these are appropriate patient teaching regarding canes.
43. When a walker is correctly fit to a patient, which of the following is true?
a. The walker will come to the patient’s hip.
b. The top bar of the walker will reach the patient’s waist.
c. The patient’s elbows will be bent at a 30-degree angle when his or her hands are on the
handles.
d. The patient’s elbows will be bent at a 90-degree angle when the patient is pushing the
walker.
44. You are working with a patient whose left leg is weak. You are instructing her on walker use.
Which instruction is most appropriate?
a. “Move your right leg forward with the walker, and then move up your left leg.”
b. “Move the walker forward, and then move your left leg forward, followed by your right
leg.”
c. “Move the walker forward, and then move your right leg forward, followed by your left
leg.”
d. “Move the walker and your left leg forward at the same time, and then move your right leg
forward.”
45. A patient has had reconstructive surgery on her right foot and must be non-weight-bearing
for 6 to 8 weeks. She has problems with balance at times. Which device(s) would be most
helpful to her during this period?
a. Knee walker
b. Crutches
c. Wheeled walker
d. Abductor pillow
e. Splint
46. Label the parts of the hip joint on the following diagram.

Write brief answers to the following questions.

47. When using a walker, where should the patient stand? What is the reason for this?

48. A patient comes into the clinic where you are working for a follow-up visit after breaking her
ankle. She has been using crutches for the past 2 weeks and is complaining of pain and
tingling in her forearms and hands. What is the most likely cause of these symptoms?

49. What is the difference in recovery of a patient who has had a direct anterior approach hip
arthroplasty and one who has had a lateral approach hip arthroplasty?
Part 4. Application and Critical Thinking Questions
Choose the correct answer(s). In some questions, more than one answer is correct. Select all
that apply.
50. You see the following orders for a patient with a newly applied cast to the right arm after a
surgery to the humerus. Which order would you question as to its accuracy?
a. “May petal cast if necessary.”
b. “Support right arm on pillows until the cast is dry.”
c. “Keep the right arm elevated at all times.”
d. “Do neurovascular checks every 4 hrs × 4, then every 8 hrs × 2.”
51. You are caring for a patient who had a partial knee replacement 2 days ago. She has orders
for CPM for 2 hours four times per day at 35 degrees of flexion. Which would concern you
the most?
a. The patient’s leg and the CPM machine are in alignment with the rest of the patient’s
body.
b. The patient complains of severe pain with each flexion of the knee.
c. The patient is using relaxation breathing to prevent tensing of the leg muscles while on the
CPM machine.
d. The platform of the CPM machine is centered beneath the patient’s knee.

Write brief answers to the following questions.

52. A patient who has had a total knee replacement asks you to take off the CPM machine after 1
hour, although it is ordered to be on for 2 hours. How will you respond?

53. A patient has a fresh plaster cast applied to the left leg from the thigh to the ankle. How will
you prevent complications as the cast dries?

54. A patient has skeletal traction applied to his left lower leg. Why is pin site care critical for
this patient?

55. A patient is in skin traction. You notice that when the bed is lowered to its lowest position,
the weights are on the floor. Why is this a problem?

Situation Question
➧ Scenario: Question 56 refers to this scenario.
You are caring for a patient post left hip replacement surgery using the lateral approach. You
heard in report that the patient is not compliant regarding limiting his hip flexion to no more than
90 degrees. You prepare to teach the patient about flexion restrictions. During your teaching, the
patient states, “I never had to be careful how I moved my hip before surgery, and that was when
it had bad arthritis in it. Now I have a new replacement, so why would I need to limit how I
move it? You say it can dislocate, but it never dislocated before.”
56. How will you respond?

Documentation Exercise
➧ Scenario: Questions 57 and 58 refer to this scenario.
You are caring for a patient named Phyllis James, who is 54 years old. Her patient ID number is
34721188. Her birthdate is 05/02/1975. She is in Room 435. Today is May 12, 2012. She has
returned to the nursing unit after having surgery to repair a left tibial fracture. She has an
immobilizer in place on her lower left leg. You are assigned to do neurovascular checks on this
patient. At 4:15 p.m. you do so, and you gather the following data:
Her pedal pulses are present in both feet, but the pulse in her right foot is stronger than the
pulse in her left foot. She can feel you run a paperclip along the bottom of both her right and her
left foot. There is no swelling in her right foot, but her left foot is puffy, with 2+ pitting edema.
Her left foot and lower leg are red, but her right foot and leg are pink. She can wiggle her toes
freely on her right foot, but the toes on her left foot only move slightly when you ask her to move
them. She says she has no pain in her right leg, but her left leg is hurting. She rates the pain at a
5. When you check her capillary refill, you note that both feet are warm to the touch and the
toenail beds on both feet refill within 3 seconds.
57. Document your data on the neurovascular checklist (Fig. 27.1).
58. Compare your data with the previous neurovascular check done in the recovery room.
Determine if further action is required. If so, document your actions on the nurse’s note form
(Fig. 27.2).

Figure 27.1 Neurovascular checklist.

Figure 27.2 Nurse’s note.