Ch 64: Arthritis and Connective Tissue Diseases

The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient's choice of which food item would indicate an understanding of the instructions? a. Eggs b. Liver c. Salmon d. Chicken

A Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.

A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? a. "Infertility can result from some medications used to control your disease." b. "Temporary remission of your signs and symptoms is common during pregnancy." c. "Autoantibodies transferred to the baby during pregnancy will cause heart defects." d. "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth."

A Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common after pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.

The nurse should teach the patient with ankylosing spondylitis the importance of a. regularly exercising and maintaining proper posture b. avoiding extremes in environmental temperatures c. maintaining patient's usual physical activity during flares d. applying hot and cool compresses for relief of local symptoms

A Patients with ankylosing spondylitis (AS) should exercise after pain and stiffness are managed. Postural control is important for minimizing spinal deformity. The exercise regimen should include back, neck, and chest stretches. Teach the patient with AS about regular exercise and attention to posture, local moist-heat applications, and knowledgeable use of drugs. Discourage excessive physical exertion during periods of active flare-up of the disease. Proper positioning at rest is essential. The mattress should be firm and the patient should sleep on the back with a flat pillow, avoiding positions that encourage flexion deformity. Postural training emphasizes avoiding spinal flexion (e.g., leaning over a desk), heavy lifting, and prolonged walking, standing, or sitting.

Four patients have been newly diagnosed with connective tissue disorders. The nurse should be aware of safety issues and interstitial lung involvement for the patient with which diagnosis? a. Polymyositis b. Reactive arthritis c. Sjögren's syndrome d. Systemic lupus erythematosus (SLE)

A Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient's risk of falls and injury. Weakened pharyngeal muscles also increase the risk for aspiration, with interstitial lung disease in up to 65% of patients. Safety concerns and interstitial lung involvement are not associated with reactive arthritis (Reiter's syndrome) or Sjögren's syndrome. Safety may be an issue later in disease progression of SLE.

Teach the patient with fibromyalgia the importance of limiting intake of which foods (select all that apply)? a. sugar b. alcohol c. caffeine d. red meat e. root vegetables

A, B, C Dietitians often urge patients with fibromyalgia to limit their intake of sugar, caffeine, and alcohol because these substances have been shown to be muscle irritants.

A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient also reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments will be included in the plan of care (select all that apply.)? a. Massage therapy b. Low-impact aerobic exercise c. Relaxation strategy (biofeedback) d. Antiseizure drug pregabalin (Lyrica) e. Morphine sulfate extended-release tablets f. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

A, B, C, D, F Massage will improve blood flow and relaxation. Low-impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation using biofeedback may decrease the patient's stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will preferably be prescribed a nonopioid pain medication, an antiseizure medication such as pregabalin to help with widespread pain, and a serotonin reuptake inhibitor for depression. Long-acting opioids such as morphine are generally avoided unless pain cannot be relieved by other medications.

A 40-yr-old African American woman has longstanding Raynaud's phenomenon. Currently, she reports red spots on her hands, forearms, palms, face, and lips. Which additional findings will the nurse expect (select all that apply.)? a. Calcinosis b. Weight loss c. Sclerodactyly d. Difficulty swallowing e. Weakened leg muscles f. Skin thickening below the elbow and knee

A, C, D, F This patient is at risk for scleroderma. The acronym CREST represents the clinical manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud's phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.

A nurse assesses a 38-yr-old patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect (select all that apply.)? a. Presence of nodules b. Consistent muscle strength c. Localized disease symptoms d. No destructive changes on x-ray e. Subluxation of joints without fibrous ankyloses f. Joint space narrowing and formation of osteophytes

A, E In stage III severe RA, extraarticular soft tissue lesions or nodules may be present along with subluxation without fibrous or bony ankylosis. Muscle strength is decreased because of extensive muscle atrophy. Manifestations are systemic rather than localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Joint space narrowing with osteophytes is consistent with osteoarthritis.

Which action will the nurse include in the plan of care for a patient with newly diagnosed ankylosing spondylitis? a. Advise the patient to sleep on the back with a flat pillow. b. Emphasize that application of heat may worsen symptoms. c. Schedule annual laboratory assessment for the HLA-B27 antigen. d. Assist patient to choose physical activities that involve spinal flexion.

ANS: A Because ankylosing spondylitis results in flexion deformity of the spine, postures that extend the spine (e.g., sleeping on the back and with a flat pillow) are recommended. HLA-B27 antigen is assessed for initial diagnosis but is not needed annually. To counteract the development of flexion deformities, the patient should choose activities that extend the spine, such as swimming. Heat application is used to decrease localized pain.

After the nurse has taught a 28-yr-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? a. "I will need to stop drinking so much coffee and soda." b. "I am going to join a soccer team to get more exercise." c. "I will call the doctor every time my symptoms get worse." d. "I should avoid using over-the-counter medications for pain."

ANS: A Dietitians frequently suggest patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management.

Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? a. Blurred vision b. Joint tenderness c. Abdominal cramping d. Elevated blood pressure

ANS: A Plaquenil can cause retinopathy. The medication should be stopped. Other findings are not related to the medication although they will also be reported.

A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? a. The blood pressure is 86/50 mm Hg. b. The patient says the knee pain is severe. c. The white blood cell count is 11,500/μL. d. The patient is taking ibuprofen (Motrin).

ANS: A The low blood pressure suggests the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should also be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

A 25-yr-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." The nurse will plan interventions with the patient to address the nursing diagnosis of a. social isolation b. activity intolerance c. impaired skin integrity d. impaired social interaction.

ANS: A The patient's statement about not going anywhere because of hating the way he or she looks expresses social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)? a. Sleep disturbances b. Multiple tender points c. Cardiac palpitations and dizziness d. Multijoint inflammation and swelling e. Widespread bilateral, burning musculoskeletal pain

ANS: A, B, E These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia.

Which information will the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self-management? a. Symptoms usually progress as patients become older. b. A gradual increase in daily exercise may help decrease fatigue. c. Avoid use of over-the-counter antihistamines or decongestants. d. A low-residue, low-fiber diet will reduce any abdominal distention.

ANS: B A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with SEID syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. SEID usually does not progress.

Which action will the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? a. Instruct the patient to purchase a soft mattress. b. Encourage the patient to take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.

ANS: B Adequate rest helps decrease the fatigue and pain associated with RA. Patients are taught to avoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When the disease is stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve flexibility and strength of affected joints, as well as the patient's general endurance.

A patient with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider? a. Red, scaly patches are noted on the arms. b. Crackles are auscultated in the lung bases. c. Hemoglobin is 11.1g/dL, and hematocrit is 35%. d. Patient has continued pain after first week of etanercept therapy.

ANS: B Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for a change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve symptoms.

The nurse determines additional instruction is needed when a patient diagnosed with scleroderma makes which statement? a. "Paraffin baths can be used to help my hands." b. "I should lie down for an hour after each meal." c. "Lotions will help if I rub them in for a long time." d. "I should perform range-of-motion exercises daily."

ANS: B Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate teaching has been effective.

Which laboratory result will the nurse monitor to determine if prednisone has been effective for a patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose b. C-reactive protein c. Serum electrolytes d. Liver function tests

ANS: B C-reactive protein is a serum marker for inflammation, and a decrease would indicate the corticosteroid therapy was effective. Blood glucose and serum electrolytes will also be monitored to assess for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.

Which information will the nurse include when preparing teaching materials for a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Applying cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

ANS: B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

Which assessment information obtained by the nurse indicates a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? a. The patient has joint pain and stiffness. b. The patient's blood glucose is 165 mg/dL. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.

ANS: B Corticosteroids have the potential to cause diabetes mellitus. The finding of elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR with no improvement in symptoms would indicate the prednisone was not effective but would not be side effects of the medication.

Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is likely to require a change in medication? a. The patient has gained 3 lb. b. The patient has dark-colored stools. c. The patient's pain affects multiple joints. d. The patient uses capsaicin cream (Zostrix).

ANS: B Dark-colored stools may indicate the patient is experiencing gastrointestinal bleeding caused by the naproxen. The patient's ongoing pain and weight gain will also be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

Which information will the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about management of the condition? a. Exercise by taking long walks. b. Do daily deep-breathing exercises. c. Sleep on the side with hips flexed. d. Take frequent naps during the day.

ANS: B Deep-breathing exercises are used to decrease the risk for pulmonary complications that may result from reduced chest expansion that can occur with AS. Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

Which result for a patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

ANS: B Elevated BUN and serum creatinine indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows decreased inflammation.

Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? a. Presence of Heberden's nodules b. Discomfort with joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

ANS: B Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests and decreases with joint movement. DIF: Cognitive Level: Understand (comprehension) REF: 1518 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep the environment warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

ANS: B Keeping the room warm will decrease the incidence of Raynaud's phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose or to assist the patient to the bathroom every 2 hours.

The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer b. Administer varicella vaccine c. Naproxen (Aleve) 200 mg BID d. Famotidine (Pepcid) 20 mg daily.

ANS: B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Which information from the patient's health history is important for the nurse to report to the health care provider related to the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

ANS: B Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma? a. Monitor for difficulty in breathing. b. Document the patient's oral intake. c. Check finger strength and movement. d. Apply capsaicin (Zostrix) cream to hands.

ANS: B Monitoring and documenting patient's oral intake is included in UAP education and scope of practice. Assessments for changes in physical status and administration of medications require more education and scope of practice, and should be done by RNs.

After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. "I can exercise every day to help maintain joint motion." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."

ANS: B No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease the risk for liver damage. Regular exercise, moist heat, and supportive equipment are recommended for OA management.

Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient has understood the nurse's teaching about the condition? a. "I will exercise even if I am tired." b. "I will use sunscreen when I am outside." c. "I should avoid nonsteroidal antiinflammatory drugs." d. "I should take birth control pills to avoid getting pregnant."

ANS: B Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

A patient with two school-age children has recently been diagnosed with rheumatoid arthritis (RA) and tells the nurse that home life is very stressful. Which initial response by the nurse is most appropriate? a. "You need to see a family therapist for some help with stress." b. "Tell me more about the situations that are causing you stress." c. "Your family should understand the impact of your rheumatoid arthritis." d. "Perhaps it would be helpful for your family to be involved in a support group."

ANS: B The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. The safety priority for the patient is addressing the a. acute pain b. risk for aspiration c. disturbed visual perception d. risk for impaired skin integrity

ANS: B The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other concerns are also appropriate but are not as high a priority as the maintenance of the patient's airway.

Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. avoiding concurrent aspirin use. b. symptoms of gastrointestinal (GI) bleeding. c. self-administration of subcutaneous injections. d. taking the medication with at least 8 oz of fluid.

ANS: C Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued.

A patient with an acute attack of gout in the right great toe has a new prescription for probenecid. Which information about the patient's home routine indicates a need for teaching regarding gout management? a. The patient sleeps 8-10 hours each night. b. The patient usually eats beef once a week. c. The patient takes one aspirin a day to prevent angina. d. The patient usually drinks about 3 quarts water each day.

ANS: C Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

The nurse is planning care for a patient with hypertension and gout who has a red, painful right great toe. Which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the right foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach the patient to avoid use of acetaminophen (Tylenol).

ANS: C Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe, and touching the toe should be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain management.

Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)? a. Rheumatoid factor is positive. b. Fasting blood glucose is 90 mg/dL. c. The white blood cell (WBC) count is 1500/μL. d. The erythrocyte sedimentation rate is elevated.

ANS: C Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose is normal.

The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which medication? a. Prednisone b. Adalimumab (Humira) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

ANS: C Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with rheumatoid arthritis.

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The most appropriate response by the nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

ANS: C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

A patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of a. sertraline (Zoloft). b. famotidine (Pepcid). c. hydrochlorothiazide. d. oxycodone (Roxicodone).

ANS: C Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.

A patient hospitalized with a fever and red, hot, painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. had several knee injuries as a teenager. b. recently returned from South America. c. is sexually active with multiple partners. d. has a parent who has rheumatoid arthritis.

ANS: C Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)? a. A 56-yr-old man who has a sedentary office job b. A 38-yr-old man who plays on a summer softball team c. A 56-yr-old woman who works on an automotive assembly line d. A 38-yr-old woman who is newly diagnosed with diabetes mellitus

ANS: C OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a risk factor for OA. Sedentary work is not a risk factor for OA.

A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules.

ANS: C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus (SLE). Which test will provide the most specific findings for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

ANS: C The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.

The nurse notices a circular lesion with a red border and clear center on the arm of a summer camp counselor who is in the clinic complaining of chills and muscle aches. Which action should the nurse take to follow up on that finding? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.

ANS: C The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest cardiac or abdominal problems or lack of immunization.

A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is appropriate? a. Ask the HCP about discontinuing methotrexate b. Remind the patient that RA is a chronic health condition. c. Suggest the patient use over-the-counter (OTC) artificial tears. d. Teach the patient about adverse effects of the RA medications.

ANS: C The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. A focus on the prognosis for RA is not helpful. The dry eyes are not caused by RA treatment but by the disease itself.

The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information requires a discussion with the health care provider about an urgent change in the treatment plan? a. Knee crepitation is noted with normal knee range of motion. b. Patient reports embarrassment about having Heberden's nodes. c. Patient's knee pain while golfing has increased over the last year. d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

ANS: D Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will also be reported to the health care provider but is consistent with the patient's diagnosis of osteoarthritis and will not require an immediate change in the patient's treatment plan.

A patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with a. methotrexate b. anakinra (Kineret). c. etanercept (Enbrel). d. doxycycline (Vibramycin).

ANS: D Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis.

The home health nurse is making a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates more patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins each day. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head.

ANS: D The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. Rest, aspirin, and energy management are appropriate for a patient with RA and indicate teaching has been effective.

In assessing the joints of a patient with osteoarthritis, the nurse understands that Bouchard's nodes a. are often red, swollen, and tender b. indicate osteophyte formation at the PIP joints c. are the result of pannus formation at the DIP joints d. occur from deterioration of cartilage by proteolytic enzymes

B Bouchard's nodes are bony deformities of the proximal interphalangeal joints that indicate osteophyte formation and loss of joint space in osteoarthritis.

When administering medications to the patient with chronic gout, the nurse would recognize which of the following as a treatment for chronic disease? a. Colchicine b. Febuxostat c. Sulfasalazine d. Cyclosporine

B Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for long-term management of hyperuricemia in persons with chronic gout. An acute episode of gout is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs).

A 66-yr-old man with type 2 diabetes mellitus and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask? a. "Did you have any hypoglycemic reactions?" b. "Have you noticed any bruising or bleeding?" c. "Have you had any dizzy spells when standing up?" d. "Do you have any numbness or tingling in your feet?"

B Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both may increase the risk of bleeding. Patients with atrial fibrillation routinely take an anticoagulant to reduce the risk of venous thromboembolism and stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose, and hyperglycemia may occur.

A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan? a. Joint destruction caused by an autoimmune process b. Degeneration of articular cartilage in synovial joints c. Overproduction of synovial fluid resulting in joint destruction d. Breakdown of tissue in non-weight-bearing joints by enzymes

B OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient's knees? a. Ulnar drift b. Pain with joint movement c. Reddened, swollen affected joints d. Stiffness that increases with movement

B Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.

Which nursing intervention would be most appropriate for a patient with Sjögren's syndrome? a. Ambulate with assistive devices b. Use lubricating eye drops frequently c. Administer acetaminophen as needed d. Apply ice or heat compresses to affected areas

B Sjögren's syndrome is an autoimmune disorder in which lymphocytes attack moisture-producing glands. Treatment is symptomatic, including adding moisture to eyes and increasing intake of fluids, especially with meals.

A patient with rheumatoid arthritis is experiencing articular involvement. The nurse recognizes these characteristic changes include (select all that apply) a. bamboo-shaped fingers b. metatarsal head dislocation in feet c. noninflammatory pain in large joints d. asymmetric involvement of small joints e. morning stiffness lasting 60 minutes or more

B, E Morning stiffness may last from 60 minutes to several hours or more, depending on disease activity. Metatarsal head dislocation and subluxation in the feet may cause pain and walking disability. Joint symptoms occur symmetrically and frequently affect the small joints of the hands (proximal interphalangeal [PIP] and metacarpophalangeal [MCP] joints) and feet (metatarsophalangeal [MTP] joints). Larger peripheral joints such as the wrists, elbows, shoulders, knees, hips, ankles, and jaw may also be involved. Rheumatoid arthritis (RA) is an inflammatory disorder. In early disease, the fingers may become spindle-shaped from synovial hypertrophy and thickening of the joint capsule.

A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern will the nurse recommend? a. Bed rest with bathroom privileges b. Daily high-impact aerobic exercise c. Regular exercise program of walking d. Frequent rest periods with minimal exercise

C A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure will the nurse recommend to slow progression of the disease? a. Use a wheelchair to avoid walking as much as possible. b. Sit in chairs that cause the hips to be lower than the knees. c. Eat a well-balanced diet to maintain a healthy body weight. d. Use a walker for ambulation to relieve the pressure on the hips.

C Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.

When reinforcing health teaching on management of osteoarthritis (OA), which patient statement indicates additional instruction is needed? a. "I can use a cane to relieve the pressure on my back and hip." b. "I should take the Naprosyn as prescribed to help control the pain." c. "I should try to stay standing all day to keep my joints from becoming stiff." d. "A warm shower in the morning will help relieve the stiffness I have when I get up."

C Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.

A female patient's complex symptomatology over the past year has led to a diagnosis of systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? a. "I'll try my best to stay out of the sun this summer." b. "I know that I have a high chance of getting arthritis." c. "I'm hoping surgery will be an option for me in the future." d. "I understand I'm going to be vulnerable to getting infections."

C Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.

The patient developed gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout? a. Limited fluid intake. b. Administration of probenecid c. Administration of allopurinol d. Administration of nonsteroidal antiinflammatory drugs (NSAIDs)

C To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the patient's aspirin will inactivate its effect, resulting in urate retention. NSAIDs for pain management will not be used, related to the aspirin, because of the potential for increased side effects.

The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement? a. "I perform range of motion exercises at least twice a day." b. "I use a heating pad for 20 minutes to reduce morning stiffness." c. "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." d. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

D Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes a. circulating immune complexes formed from IgG autoantibodies reacting with IgG b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles d. the production of a variety of autoantibodies directed against components of the cell nucleus

D Systemic lupus erythematosus (SLE) is marked by production of many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins. Autoimmune reactions (antinuclear antibodies [ANA]) are typically directed against constituents of the cell nucleus, especially DNA.

Which patient statement suggests a need to assess the patient for ankylosing spondylitis (AS)? a. "My right elbow has become red and swollen over the last few days." b. "I wake up stiff every morning, and my knees just don't want to bend." c. "My husband tells me that my posture has become so stooped this winter." d. "My lower back pain seems to be getting worse and nothing seems to help."

D AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.

A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor a. blood glucose b. blood pressure c. erythrocyte count d. lymphocyte count

ANS: B Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a. a brief routine of isometric exercises. b. a warm bath followed by a short rest. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

ANS: B Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites? a. The best therapy for the acute illness is an IV antibiotic. b. Check for an enlarging reddened area with a clear center. c. Surveillance is necessary during the summer months only. d. Antibiotics will prevent Lyme disease if taken for 10 days.

B After a tick bite, the expanding "bull's eye rash" is the most characteristic symptom that usually occurs in 3 to 30 days. Flu-like symptoms and migrating joint and muscle pain also may be present. Active lesions are treated with oral antibiotics for 2 to 3 weeks; doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. No vaccine is available.

In teaching a patient with Sjögren's syndrome about drug therapy for this disorder, the nurse includes instruction on use of which drug? a. Pregabalin (Lyrica) b. Etanercept (Enbrel) c. Cyclosporine (Restasis) d. Cyclobenzaprine (Flexeril)

C Cyclosporine (Restasis) ophthalmic drops can be used to treat the chronic dry eye associated with Sjögren's syndrome.

The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding a. reduced joint pain. . b. increased urine output. c. elevated serum uric acid d. increased white blood cells (WBC).

ANS: A Colchicine reduces joint pain in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day during acute gout would increase urine output but would not indicate the effectiveness of colchicine. Elevated serum uric acid would result in increased symptoms. The WBC count might decrease with decreased inflammation but would not increase.

A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding by the nurse is important to report to the health care provider? a. The patient has painful hematuria. b. Acne is noted on the patient's face. c. Fasting blood glucose is 112 mg/dL. d. The patient has an increased appetite.

ANS: A Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should a. avoid activities requiring repetitive use of the same muscles and joints. b. protect the knee joints by sleeping with a small pillow under the knees. c. stand rather than sit when performing daily household and yard chores. d. strengthen small hand muscles by wringing out sponges or washcloths.

ANS: A Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase joint stress. Patients are encouraged to position joints in the extended (neutral) position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion.