CH 18
The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will also have which common condition? Dry eyes Abdominal bloating after eating Excessive production of saliva in the mouth Intermittent episodes of diarrhea
A Clients with Sjögren's syndrome experience dry eyes (keratoconjunctivitis sicca). Abdominal bloating, excessive saliva production, and diarrhea are not common conditions in clients with Sjögren's syndrome; however, dry mouth is commonly described.
Before administering low-molecular-weight heparin (LMWH) to an older adult client after total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3. What action is most important for the nurse to take? Notify the health care provider of the platelet count. Administer the prescribed LMWH on schedule. Assess the activated partial thromboplastin time (aPTT). Assess the international normalized ratio (INR).
A If the platelet count falls below 20,000/mm3, spontaneous bleeding could occur. Notifying the health care provider before the LMWH is given is essential. LMWH can cause thrombocytopenia, so it should not be administered when the client's platelet count is low. The aPTT is not affected by LMWH, so its assessment is not necessary. Usually, LMWH is given in a low prophylactic dose and does not affect the INR.
Which element is a risk factor for osteoarthritis (OA)? Thin build Obesity Nonsmoker Male
B Being obese, not thin, places an individual at higher risk for slow joint degeneration and the development of OA. Smoking leads to knee cartilage loss, especially in clients with a family history of knee OA. Women tend to develop OA more than men, and it is believed that obesity may be a contributing factor; as women age and have children, they tend to gain more weight than men.
A client has symptoms of rheumatoid arthritis (RA). Which laboratory finding indicates to the nurse that the client may have RA? Total serum complement, 75 units/mL Positive total antinuclear antibody (ANA) Erythrocyte sedimentation rate (ESR), 20 mm/hr Beta-globulin level, 1.0 g/dL
B Elevation of total ANA is common in systemic lupus erythematosus, systemic sclerosis, and RA. A serum complement of 75 units/mL is the normal range for total serum complement. An ESR rate of 22 mm/hr is normal for a female. A beta-globulin level of 1.0 g/dL is normal.
Before administering prednisone IV push to a middle-aged adult with rheumatoid arthritis (RA), the nurse notes that the client's random blood glucose level is 139. Which action is most important for the nurse to take? Instruct the client to drink diet soda to prevent elevation of blood sugar. Administer the prescribed prednisone on schedule. Notify the health care provider of the random blood glucose result. Review the client's antinuclear antibody (ANA) level.
B For this client, giving the medication per schedule is essential in treating the disease. The blood glucose value will be monitored regularly because the client is receiving prednisone. Blood sugar is only slightly elevated; encourage fluids other than soda (diet or otherwise). Blood glucose levels are performed and parameters are set as to when the health care provider should be notified, but usually this is done only if the random blood glucose level is greater than 150. Reviewing the client's ANA level is not required before prednisone is given; the client's ANA is elevated because of the RA.
The nurse is caring for an older adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? "I do not know how long my wife will be able to take care of me at home." "The bus is coming to pick me up from the senior center three times a week so I can play cards." "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." "I do not know how much longer my neighbor can continue to help clean my house."
B Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support. Caregiving responsibilities can be a source of stress; the client worrying about his wife's caregiving abilities does not indicate that the client is effectively coping. Routine tasks, such as doing dishes and laundry, need to be reassigned or effective pain management should be instituted before activities are undertaken to demonstrate effective coping. Neighbors are not reliable resources for in-home needs, and asking a neighbor to help does not indicate that the client is coping effectively.
Which factor indicates to the nurse the only similarity between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)? Feeling tired and having a temperature that runs about 100° F (37.8° C) during the day Disfiguring and embarrassing rash Peripheral neuropathies and cranial nerve palsies High risk for renal inflammation
B Skin lesions are common to SLE and DLE. Fatigue and fever are common only to SLE. Neurologic manifestations and inflammation of the kidneys are common in SLE.
Which statement indicates to the nurse that a client with fibromyalgia syndrome is using a complementary therapy to help relieve symptoms? "My Thera-Band really helps me loosen up my arms." "The brace on my lower leg is helping me walk better." "Focusing on the slow stretching movements and my breathing in tai chi helps me relax." "Water aerobic exercises have helped me sleep better."
C Tai chi is an alternative or complementary therapy that focuses on slow and gentle stretching movements and breathing. Thera-Band exercises are used in physical therapy. Splints or braces are used in occupational therapy. Water aerobics is an example of a low-impact exercise, not alternative therapy.
The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies? "I'm letting my husband do most of the cooking, but I help plan the menus." "Since I started taking etanercept (Enbrel), I can walk up and down the stairs of my home easier." "My husband is getting used to having sex only once a month." "I worry about what's going to happen to me if my husband cannot take care of me, but he says he'll hire someone if he must."
C The client's comment that her husband is getting used to sex only once a month could indicate negative body image or depression; additional open-ended questions by the nurse are required. Being involved in the meal process is a productive coping strategy. The client's statement about the positive effects of etanercept therapy indicates productive coping because it describes improved mobility. Expressing concerns about the future but then identifying a plan is a productive coping strategy.
The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis (RA) who has been ordered to start sulfasalazine (Azulfidine) therapy. The nurse plans to contact the health care provider if the client has which condition? Glaucoma Hypertension Hypothyroidism Sulfa allergy
D Sulfasalazine contains sulfa and is contraindicated in clients with sulfa allergies. Sulfasalazine (Azulfidine) is not contraindicated in clients with glaucoma, hypertension, or hypothyroidism.
The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? Begin a running program. Take up knitting to slow down joint degeneration. Eat at least 2 cups of yogurt per day. Wear supportive shoes.
D Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints. Running promotes stress on joints and should be avoided. Repetitive stress activities such as knitting or typing should be avoided for prolonged periods. No single food can cure OA; a well-balanced diet is recommended.
The home health nurse conducts a community presentation on Lyme disease for the residents of an assisted-living facility. Which statement from the audience indicates to the home health nurse that further instruction is needed? "I will gently remove the tick with tissue and then burn it to prevent the spread of the disease." "It is best to walk in the center of the trail." "I should wait 4 to 6 weeks after being bitten by a tick to be tested for Lyme disease." "I'll wear light-colored clothes with long sleeves, long pants, closed shoes, and a hat when I am walking in the woods."
A Burning a Lyme disease-carrying tick could spread infection, so flushing it down the toilet is the recommended disposal method; this statement indicates that further instruction is needed. Walking in the center of the trail is a protective measure against Lyme disease. If bitten, testing is not reliable until 4 to 6 weeks later. Wearing light-colored clothes, long pants, long sleeves, closed shoes, and hat are appropriate skin protection measures against Lyme disease.
Which instructions for joint protection does the nurse recommend for a client with a connective tissue disease? (Select all that apply.) Use long-handled devices such as a reacher. When getting out of bed, use fingers to push off. Sit in a low back chair. Bend at the waist while keeping the back straight. Use adaptive devices such as Velcro closures. Turn a doorknob clockwise.
AE Use of long-handled devices such as a reacher and other adaptive devices, such as Velcro closures, helps to protect the joints. When getting out of bed, the client should not push off with fingers, but use the entire palm of both hands. Clients with connective tissue disease should sit in a chair that has a high, straight back, and should bend at the knees while keeping the back straight. Doorknobs should be turned counterclockwise to avoid twisting the arm and promoting ulnar deviation.
A client diagnosed with exacerbation of systemic sclerosis (SSc) asks the nurse why a foot board and a bed cradle have been placed on the bed. The nurse explains that they are used for what purpose? Inspect skin for lesions or changes Promote comfort from Raynaud's phenomenon Prevent foot drop and contractures Decrease chilling of the extremities
B Acute pain occurs during Raynaud's phenomenon (the first symptom that occurs with SSc), and avoiding pressure from bed linens is a comfort measure. Skin ulcers and lesions can occur with SSc, but a foot board and a bed cradle do not assist with skin inspection. Bed cradles do not prevent foot drop or contractures; only foot boards do this. Decreased chilling and reduced vasospasms of the extremities can be accomplished by increasing the room temperature.
In teaching a client with acute secondary gout, which instruction about preventing recurrence is most important for the nurse to include? "Limit your intake of fruits and vegetables." "Weight Watchers has healthy meal plans." "Limit fluid intake to 1500 mL/day." "Discuss with your health care provider about having your estrogen and progesterone levels checked to see where you are in menopause."
B Crash diets and obesity are causes of secondary gout; avoiding crash diets and keeping fit will prevent recurrence. Eating plenty of fruits and vegetables should be encouraged because they are low in purines, which may reduce the recurrence of gout. Fluids dilute urine and prevent the formation of urinary stones, so fluid intake should not be restricted. Primary gout affects postmenopausal women, so checking estrogen and progesterone levels is not indicated.
Assessment findings reveal that an older adult client with severe osteoarthritis of the left hip can no longer perform activities of daily living (ADLs) and has had several falls in the home over the past month. To which community resource does the nurse refer the client? Local senior citizen center Citizens for Better Care Home health care agency Meals on Wheels
C Home health care referrals can order a nurse to evaluate the home situation and notify the health care provider of any in-home needs, such as an aide, physical therapist, or social worker. Senior citizen centers provide activities, meals, and sometimes transportation, but do not help with ADLs. Citizens for Better Care is concerned with clients' rights and safety in health care facilities. The home health care agency may make a referral to Meals on Wheels if it is indicated, but this will not help with all ADLs or safety measures.
A client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy? "Drinking alcoholic beverages should be avoided." "The health care provider should be notified 3 months before a planned pregnancy." "Any side effects of this drug will be mild." "I will avoid any live vaccines."
C Methotrexate can have devastating side effects and toxic effects, and the client should be carefully monitored when taking this drug; this statement indicates the client needs further clarification. Alcoholic beverages increase the risk for hepatotoxicity and should be avoided. Strict birth control is recommended for any client of childbearing age because of the possibility of birth defects. Severe reactions may occur when live vaccines are given because of the immunosuppressive effect of methotrexate.
A client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? Use an abduction pillow between the legs. Keep heels off the bed. Avoid using a straight razor. Re-orient frequently.
C The client will be on anticoagulants for 4 to 6 weeks at home and should avoid injury to the skin, including when shaving. Using an abduction pillow between the legs is usually done immediately after surgery, especially if the client is confused or restless and cannot maintain proper joint positioning. Keeping the heels off the bed prevents pressure ulcers during the in-hospital postoperative period. Changes in mental status can occur immediately after surgery as a result of anesthesia.
The nurse is teaching a client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching? "RA is inflammatory. OA is degenerative." "The risk factors or causes of RA are probably autoimmune, whereas OA may be caused by age, obesity, trauma, or occupation." "The typical onset of RA is seen between 35 and 45 years of age, whereas the typical onset of OA is seen in clients older than 60 years." "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints."
D OA is unilateral and usually affects a single joint, whereas RA is bilateral and affects multiple joints; this statement by the client indicates the need for further teaching. RA is indeed an inflammatory process, while OA is a degenerative process. Research is being done to find a possible genetic cause for OA, but age, trauma, obesity, and occupation are the main causes of degeneration. RA occurs most often in women, usually between 35 and 45 years of age, whereas older age is a cause of OA.
The nurse is caring for a postoperative client with total joint arthroplasty. What actions does the nurse take to prevent venous thromboembolism (VTE) postoperatively? (Select all that apply.) Massage the legs. Keep the legs slightly abducted. Use the knee gatch on the bed. Apply elastic stockings. Administer anticoagulants.
DE Support stockings provide compression, which helps prevent VTE. Anticoagulants help prevent VTE because they inhibit the formation of blood clots. Massaging the legs could cause a blood clot to dislodge and should be avoided. Legs are kept slightly abducted to prevent adduction. Using the knee gatch can constrict circulation in the popliteal area and should be avoided.