Ch 64

Which action should the nurse include in the plan of care for a patient with newly diagnosed ankylosing spondylitis? 1. Have the patient sleep on their back with a flat pillow. 2. Discuss that application of heat may worsen symptoms. 3. Schedule annual laboratory assessment for the HLA-B27 antigen. 4. 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.

What finding should indicate to the nurse that colchicine has been effective for a patient with an acute attack of gout? 1. Reduced joint pain 2. Increased urine output 3. Elevated serum uric acid 4. Increased white blood cells

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 should the nurse report immediately to the health care provider? 1. The patient has painful hematuria. 2. Acne is noted on the patient's face. 3. Fasting blood glucose is 112 mg/dL. 4. 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.

After teaching a 28-yr-old with fibromyalgia about the disease, which patient statement does the nurse determines indicates a good understanding of effective self-management? 1. "I will need to stop drinking so much coffee and soda." 2. "I am going to join a soccer team to get more exercise." 3. "I will call the doctor every time my symptoms get worse." 4. "I should avoid using over-the-counter medications for pain."

ANS: A Dietitians often 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 should the nurse identify as a likely 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 should the nurse report immediately to the health care provider? 1. The blood pressure is 86/50 mm Hg. 2. The patient says the knee pain is severe. 3. The white blood cell count is 11,500/μL. 4. 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 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) has a facial rash and alopecia. She tells the nurse, "I never leave my house because I hate the way I look." Which patient problem should the nurse plan to address? 1. Social isolation 2. Activity intolerance 3. Impaired skin integrity 4. 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.

Which information should the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self-management? 1. Symptoms usually progress as patients become older. 2. A gradual increase in daily exercise may help decrease fatigue. 3. Avoid use of over-the-counter antihistamines or decongestants. 4. 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 should the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? 1. Instruct the patient to purchase a soft mattress. 2. Encourage the patient to take a nap in the afternoon. 3. Teach the patient to use lukewarm water when bathing. 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 physical therapist usually develops a therapeutic exercise program that includes exercises that improve flexibility and strength of affected joints, as well as the patient's general endurance.

Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). What information should the nurse include in teaching the patient about this drug? 1. Avoiding aspirin use. 2. Giving subcutaneous injections. 3. Taking the medication with water. 4. Recognizing gastrointestinal bleeding.

ANS: B 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 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 psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider? 1. Red, scaly patches are noted on the arms. 2. Crackles are auscultated in the lung bases. 3. Hemoglobin is 11.1g/dL, and hematocrit is 35%. 4. Patient has continued pain after first week of 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 should determine additional instruction is needed when a patient diagnosed with scleroderma makes which statement? 1. "Paraffin baths can be used to help my hands." 2. "I should lie down for an hour after each meal." 3. "Lotions will help if I rub them in for a long time." 4. "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 should the nurse monitor to determine if prednisone has been effective for a patient who has an acute exacerbation of rheumatoid arthritis? 1. Blood glucose 2. C-reactive protein 3. Serum electrolytes 4. 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 should the nurse include when preparing teaching materials for a patient who has an exacerbation of rheumatoid arthritis? 1. Affected joints should not be exercised when pain is present 2. Applying cold packs before exercise may decrease joint pain 3. Exercises should be performed passively by someone other than the patient 4. 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 should indicate to the nurse that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? 1. The patient has joint pain and stiffness. 2. The patient's blood glucose is 165 mg/dL. 3. The patient has experienced a recent 5-pound weight loss. 4. The patient's erythrocyte sedimentation rate (ESR) has increased.

ANS: B Corticosteroids have the potential to cause diabetes. 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.

The nurse is assessing a patient with osteoarthritis who uses naproxen (Naproxyn) for pain management. Which assessment finding should the nurse recognize as likely to require a change in medication?a. The patient has gained 3 pounds. 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 should the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about managing the condition? 1. Exercise by taking long walks. 2. Do daily deep-breathing exercises. 3. Sleep on the side with hips flexed. 4. 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.

A patient with gout has a new prescription for losartan (Cozaar). What should the nurse plan to monitor? 1. Blood glucose 2. Blood pressure 3. Erythrocyte count 4. Lymphocyte count

ANS: B Losartan may be effective for treating older patients with gout and hypertension. Losartan promotes urate excretion and may normalize serum urate. Losartan, an angiotensin II receptor antagonist, should lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.

Which result for a patient with systemic lupus erythematosus (SLE) should the nurse identify as most important to communicate to the health care provider? 1. Decreased C-reactive protein (CRP) 2. Elevated blood urea nitrogen (BUN) 3. Positive antinuclear antibodies (ANA) 4. 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 should the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? 1. Presence of Heberden's nodules 2. Discomfort with joint movement 3. Redness and swelling of the knee joint 4. 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.

A patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action should the nurse include in the plan of care? 1. Avoid use of capsaicin cream on hands. 2. Keep the environment warm and draft free. 3. Obtain capillary blood glucose before meals. 4. 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 should the nurse question? 1. Draw anti-DNA blood titer. 2. Administer varicella vaccine. 3. Naproxen 200 mg twice daily. 4. 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. Considering this treatment, which information should the nurse report to the health care provider? 1. The patient had a history of infectious mononucleosis as a teenager. 2. The patient is trying to get pregnant before her disease becomes more severe. 3. The patient has a family history of age-related macular degeneration of the retina. 4. 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 action for the care of a patient who has scleroderma can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? 1. Monitor for difficulty in breathing. 2. Document the patient's oral intake. 3. Check finger strength and movement. 4. 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.

Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient understands the nurse's teaching about the condition? 1. "I will exercise even if I am tired." 2. "I will use sunscreen when I am outside." 3. "I should avoid nonsteroidal anti-inflammatory drugs." 4. "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.

How should the nurse suggest that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day? 1. A brief routine of isometric exercises 2. A warm bath followed by a short rest 3. Active range-of-motion (ROM) exercises 4. 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.

A patient has recently been diagnosed with rheumatoid arthritis (RA) The patient, who has two school-age children, tells the nurse that home life is very stressful. Which initial response should the nurse make? 1. "You need to see a family therapist for some help with stress." 2. "Tell me more about the situations that are causing you stress." 3. "Perhaps it would be helpful for your family to be in a support group." 4. "Your family should understand the impact of your rheumatoid arthritis."

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. What safety priority should the nurse identify for this patient? 1. Acute pain 2. Risk for aspiration 3. Impaired tissue integrity 4. Disturbed visual perception

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.

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 should the nurse understand indicates a need for teaching regarding gout management? 1. The patient sleeps 8-10 hours each night. 2. The patient usually eats beef once a week. 3. The patient takes one aspirin a day to prevent angina. 4. 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.

A patient with hypertension and gout has a red, painful right great toe. Which action should the nurse include in the plan of care for this patient? 1. Gently palpate the toe to assess swelling. 2. Use pillows to keep the right foot elevated. 3. Use a footboard to hold bedding away from the toe. 4. Teach the patient to avoid 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.

A patient is taking methotrexate to treat rheumatoid arthritis (RA). Which laboratory result is important for the nurse to communicate to the health care provider? 1. Rheumatoid factor is positive. 2. Fasting blood glucose is 90 mg/dL. 3. The white blood cell count is 1500/μL. 4. The erythrocyte sedimentation rate is increased.

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 should anticipate the need to teach a patient who has osteoarthritis (OA) about which medication? 1. Prednisone 2. Adalimumab (Humira) 3. Capsaicin cream (Zostrix) 4. 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." What is the most appropriate response by the nurse? 1. "You have the right to refuse to take the methotrexate." 2. "Methotrexate is less expensive than some of the newer drugs." 3. "It is important to start methotrexate early to decrease the extent of joint damage." 4. "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 gout arthritis. Which medication should the nurse discuss with the health care provider before administering a prescribed dose? 1. sertraline (Zoloft). 2. famotidine (Pepcid). 3. hydrochlorothiazide. 4. oxycodone (Roxicodone).

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

Which information from a patient's health history should the nurse identify as a risk factor for septic arthritis? 1. Recently visited South America 2. Several knee injuries as a teenager 3. Sexually active with several partners 4. 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.

The nurse teaches a patient with osteoarthritis (OA) of the hip about how to manage the OA. Which patient statement indicates to the nurse a need for additional teaching? 1. "A shower in the morning will help relieve stiffness." 2. "I can exercise every day to help maintain joint mobility." 3. "I will take 1 gram of acetaminophen (Tylenol) every 4 hours." 4. "I can use a cane to decrease the pressure and pain in my hip."

ANS: C 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.

A new clinic patient with joint swelling and pain is having diagnostic tests. Which test should the nurse identify as specific to systemic lupus erythematosus? 1. Rheumatoid factor (RF) 2. Antinuclear antibody (ANA) 3. Anti-Smith antibody (Anti-Sm) 4. 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.

What suggestion should the nurse make to a group of women with rheumatoid arthritis (RA) about managing activities of daily living? 1. Protect the knee joints by sleeping with a small pillow under the knees. 2. Strengthen small hand muscles by wringing out sponges or washcloths. 3. Avoid activities requiring repetitive use of the same muscles and joints. 4. Stand rather than sit when performing daily household and yard chores.

ANS: C 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.

A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action should the nurse take? 1. Draw blood for rheumatoid factor analysis. 2. Teach the patient about injections for the nodules. 3. Assess the nodules for skin breakdown or infection. 4. 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.

The nurse notices a circular lesion with a red border and clear center on the arm of a patient who is in the clinic reporting chills and muscle aches. Which action should the nurse take to follow up on that finding? 1. Auscultate the heart sounds. 2. Palpate the abdomen for masses. 3. Ask the patient about recent outdoor activities. 4. 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) tells the clinic nurse about having chronically dry eyes. Which action should the nurse take? 1. Ask the HCP about discontinuing methotrexate. 2. Remind the patient that RA is a chronic health condition. 3. Suggest the patient use over-the-counter (OTC) artificial tears. 4. 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 eyedrops 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.

Which patient seen by the nurse in the outpatient clinic is most likely to need teaching about ways to reduce the risk for osteoarthritis (OA)? 1. A 56-yr-old man who has a sedentary office job 2. A 38-yr-old man who plays on a summer softball team 3. A 38-yr-old woman who is newly diagnosed with diabetes 4. A 56-yr-old woman who works on an automotive assembly line

ANS: D OA is more likely to occur in women as a result of estrogen reduction at menopause and in persons 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.

The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information should the nurse discuss with the health care provider for an urgent change in the treatment plan? 1. Knee crepitation is noted with normal knee range of motion. 2. Patient reports embarrassment about having Heberden's nodes. 3. Patient's knee pain while golfing has increased over the last year. 4. 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 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. What long-term therapy should the nurse plan to explain to the patient? 1. methotrexate 2. anakinra (Kineret) 3. etanercept (Enbrel) 4. 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 recently diagnosed with rheumatoid arthritis (RA). Which finding indicates to the nurse that additional patient teaching is needed? 1. The patient takes a 2-hour nap each day. 2. The patient has been taking 16 aspirins each day. 3. The patient sits on a stool while preparing meals. 4. 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.