CHAPTER 18: CARE OF PATIENTS WITH ARTHRITIS AND OTHER CONNECTIVE TISSUE DISEASES

27. A client had a total knee replacement this morning and has a continuous passive motion (CPM) machine. What activity related to the CPM does the RN delegate to the unlicensed assistive personnel? a. Placing controls out of the reach of confused clients b. Assessing the client's response to the CPM c. Teaching the client's family the rationale for the CPM d. Assessing neurovascular status of the leg in the CPM

ANS: A All activities are appropriate for the client with a CPM, but the nurse can delegate only the task of keeping controls out of reach of the confused client. All other activities would need to be performed by the RN.

33. The nurse is caring for a client who has dysphagia caused by systemic sclerosis. What is the best intervention for the nurse to implement for this client? a. Encourage frequent, high-protein, easy to swallow foods. b. Teach the client to lie flat after meals to prevent reflux. c. Thicken liquids to a nectar or honey consistency. d. Have the client hyperextend his or her neck while swallowing.

ANS: A Clients with dysphagia frequently have esophageal motility problems, and swallowing becomes difficult. This, combined with malabsorption, leads to a malnourished client. Frequent small meals consisting of high-protein and easy to swallow foods are best. Clients should eat only in an upright position to reduce choking. Thickening liquids may help, but this does not address the malnutrition. Hyperextending the neck may help, but specific techniques should be determined by a swallowing study.

37. A client with rheumatoid arthritis had abdominal surgery and has returned to the postoperative nursing unit. The client is unable to use the incentive spirometer correctly, demonstrating limited lung volume and fatiguing easily. What action by the nurse takes priority? a. Notify the physician immediately. b. Have respiratory therapy re-instruct the client. c. Assess for pain and medicate if necessary. d. Let the client rest for a few hours.

ANS: A Clients with rheumatoid arthritis can have cervical spine involvement resulting in subluxation. This may lead to decreased respiratory function and can be life threatening. This client was recently intubated for an operation and so is at higher risk for this problem. The nurse should notify the physician immediately and continue assessing the client.

4. An older adult client is scheduled for knee replacement surgery. Which statement by the client indicates a need for further preoperative instruction? a. "I need to keep my leg positioned away from my body." b. "I may have a continuous passive motion machine for a few days." c. "I may need more pain medicine than I did with my hip replacement." d. "I probably can get back to work within 2 to 3 weeks."

ANS: A Dislocation is not a problem with knee replacement surgery, so the client does not need to keep his or her leg abducted. The other statements indicate accurate understanding of the instructions.

18. A client with a history of rheumatoid arthritis will be starting drug therapy with etanercept (Enbrel). What is most important for the nurse to teach the client? a. The correct technique for subcutaneous injections b. How to self-monitor blood glucose levels c. How to set up and prime the IV tubing d. How to calculate the dosage based on symptoms

ANS: A Enbrel is a parenteral medication that is given by subcutaneous injection. The client and/or the family will need to be taught how to give a subcutaneous injection correctly. Blood glucose levels should not be affected by this medication. The medication is not administered IV. Drug dosages are not changed and recalculated by the client.

36. The nurse is caring for a female client who has a history of chronic fatigue syndrome. Which finding is the nurse surprised to see in the client's record? a. Hemoglobin, 7.2 g/dL b. Serum creatinine, 0.9 mg/dL c. Multiple tender lymph nodes d. Newly red, swollen, warm knee

ANS: A Laboratory values are typically normal for chronic fatigue syndrome, and no laboratory test can confirm the disease. A hemoglobin level of 7.2 is very low and is not seen with chronic fatigue syndrome. The creatinine value is normal. Tender lymph nodes and inflamed joints are normal findings in chronic fatigue syndrome.

15. The nurse is caring for a client who has had hip replacement surgery 2 days before. The client reports severe pain at the surgical site despite having received 2 Vicodin (acetaminophen and hydrocodone) tablets 2 hours previously. The client is requesting IV pain medication. What is the nurse's primary intervention? a. Assess the surgical site for signs of infection. b. Administer 2 more Vicodin tablets. c. Apply a large ice bag to the operative site. d. Reassure the client that the Vicodin will work soon.

ANS: A Most clients do not need IV pain medication after the first day. If the client seems to be having unusual pain, the nurse should first assess the client for other problems, such as a joint infection. If findings are normal, applying ice to the hip will help to reduce swelling and pain. It is not time for another dose of Vicodin, because it has only been 2 hours. The nurse would not contact the surgeon unless all pain methods tried did not work. The Vicodin should have worked within 2 hours, so the nurse should not tell the client that the Vicodin will work shortly.

1. The nurse is teaching a community health class about health promotion techniques. Which statement by a student indicates a strategy to help prevent the development of osteoarthritis? a. "I will keep my BMI under 24." b. "I will switch to low-tar cigarettes." c. "I will start jogging twice a week." d. "I will have a family tree done."

ANS: A Obesity increases the stress on weight-bearing joints and contributes to the development of degenerative joint disease. Smoking does not decrease risk for osteoarthritis. Jogging increases the risk because of increased wear and tear on the joints. There is a genetic link to osteoarthritis; creating a family tree might help the client discover if there is any familial link but will not help prevent the disorder.

9. The nurse is caring for a client who is 1 day post total hip replacement. The nurse is instructing the client about how to perform quadriceps-setting exercises correctly. Which direction does the nurse provide to the client? a. "Straighten your legs and push the back of your knees into the mattress." b. "Straighten your legs and bring each leg separately off the mattress 6 inches." c. "Raise each leg 10 inches off the bed, keep it straight, and make ankle circles." d. "Bend each knee, and rapidly point your toes downward and then upward."

ANS: A Quadriceps-setting exercises are done by straightening the leg as much as possible by attempting to push the back of the knees into the mattress. The other exercises may be performed by the client as tolerated, but these items do not describe quadriceps-setting exercises.

21. The school nurse removes a tick embedded in a student's scalp by the hairline. Which follow-up instruction is the nurse sure to provide to the mother? a. "Call your pediatrician right away if a fever or a red rash develops at the bite." b. "If your child does not have symptoms within 2 weeks, you can relax." c. "Call your pediatrician tomorrow to get antibiotics to prevent Lyme disease." d. "Keep the site clean, but you don't have to worry about further problems."

ANS: A The mother should be instructed to monitor for early symptoms of Lyme disease (fever, rash at the site, other flulike symptoms) following a tick bite. Symptoms can appear for up to 30 days after the bite. Antibiotics are not prescribed as a preventive measure. Because Lyme disease can cause serious complications, the mother needs to monitor the child's condition carefully.

28. A client with chronic gout takes probenecid (Benemid) and comes to the clinic reporting frequent severe headaches and a new gout flare. The client is frustrated because the gout had been under good control. Which question by the nurse is most helpful? a. "What do you take for your headaches?" b. "Do you know what triggers your gout?" c. "Have you been following your diet?" d. "Did you switch from wine to beer lately?"

ANS: A The nurse needs to assess what has changed for this client. The new onset of headaches should prompt the nurse to question the client about pain medications because aspirin inactivates probenecid. Gout can have triggers, but the client probably knows them by now if it has been well controlled. Nutritional therapy for gout remains controversial. Excessive alcohol can trigger an episode, but beer does not contribute any more than wine.

6. The nurse is caring for a postoperative client on the medical-surgical unit following a total left hip replacement the previous day. During the assessment, the nurse notes that the client's left leg is cool, with weak pedal pulses. What is the nurse's first action? a. Assess circulatory status of the right leg. b. Notify the surgeon immediately. c. Measure leg circumference at the calf. d. Check for bilateral Homans' signs.

ANS: A The symptoms may represent impaired circulation or may be normal for this client. Before the surgeon is notified, the status of the nonoperative leg should be assessed and assessment findings on both legs compared with the client's baseline. Homans' sign (pain in the calf on dorsiflexion of the foot) is not always indicative of a deep vein thrombosis and should not be evaluated until other assessments are made. Measuring calf circumference would provide additional data related to deep vein thrombosis.

35. The nurse is working at a clinic, where several clients are waiting to be seen. Which client does the nurse assess first? a. Client with temporal arteritis with new onset of blurry double vision b. Client with polymyalgia rheumatica with low-grade fever and fatigue c. Client with polymyositis reporting generalized rash and joint pain d. Client with ankylosing spondylitis who presents with back pain and weight loss

ANS: A Vision changes in a client with temporal arteritis are a dangerous sign that warrants immediate medical attention. The other clients' signs and symptoms are commonly seen with their conditions and may be addressed on a more routine basis.

14. A client who has had total hip replacement surgery asks the nurse when she will be able to use a regular-height toilet seat again. What is the nurse's best response? a. "As soon as you are able to walk without a limp." b. "As soon as the staples are removed from the incision." c. "When you are off pain medication and warfarin (Coumadin)." d. "When you can hold your leg 6 inches off the bed for 5 full minutes."

ANS: A When the client is able to walk without a limp, the artificial joint is seated sturdily enough in place that it will not be dislocated or dislodged by overflexing it. At that time, the client will no longer need assistive devices or ambulatory aids. With staples removed, holding the leg off the bed and taking Coumadin do not affect readiness to bend the hip enough to use a regular toilet seat.

2. After hip replacement surgery, a client receives two doses of enoxaparin (Lovenox) during the day shift. What orders does the nurse anticipate for the client? (Select all that apply.) a. Laboratory draw for platelet count b. Laboratory draw for prothrombin time (PTT) c. Laboratory draw for international normalized ratio (INR) d. Order for protamine sulfate e. Order for vitamin K

ANS: A, D Lovenox is a low-molecular-weight heparin. Side effects can include thrombocytopenia. The antidote for all heparin products is protamine sulfate, although it will not be as effective for Lovenox as it is for unfractionated heparin.

41. The nurse is caring for an older adult client who will be discharged home to live with an adult daughter. The client will be given prescriptions for four new medications for rheumatoid arthritis. How does the nurse ensure that the client will be able to take the medications correctly at home? a. Monitor the client self-administering medications while in the hospital. b. Include the client's daughter when teaching the client about the medications. c. Provide the client with pamphlets and information about all the medications. d. Make a chart showing which medications the client should take at different times. .

ANS: B Because the client will be living with the daughter, she should be included in the teaching plan about the medications. Providing pamphlets or charts about the medications does not ensure that the client knows how to take them correctly at home. Self-administering medications may or may not be permitted by hospital policy and might be helpful, but including the daughter would be the best option

8. A client is receiving warfarin (Coumadin) daily following total hip replacement surgery. Which laboratory value requires intervention by the nurse? a. Potassium (K+), 4.2 mEq/L b. International normalized ratio (INR), 5.1 c. Prothrombin time (PT), 13.4 seconds d. Hemoglobin (Hg), 16 g/dL

ANS: B Blood levels of Coumadin will be monitored by checking daily PT and INR (in some places, only INR). The INR is critically high. The K+ is normal and is not monitored for Coumadin therapy. The PT is used in some facilities to monitor Coumadin therapy. Hemoglobin would be important to assess because a side effect of Coumadin is bleeding, and a dropping hemoglobin level would indicate that bleeding was occurring. PT and hemoglobin are within the normal range.

13. A client had a total knee replacement earlier in the day and has a continuous femoral nerve blockade (CFNB). When entering the room to assess the client, the nurse notes that the television volume is quite loud. The client explains that it is hard to hear with "all the ringing in my ears." What action by the nurse takes priority? a. Perform a neurovascular assessment on the operative extremity. b. Call another nurse to notify the anesthesiologist immediately. c. Take a full set of vital signs and discontinue the CFNB. d. Pad the siderails and instituting other seizure precautions.

ANS: B CFNB can enter the systemic circulation, causing tinnitus, nervousness, slurred speech, bradycardia, hypotension, bradypnea, and seizures. Because the client is exhibiting signs the CFNB has entered his or her circulation, the client is at risk for seizures and critical alterations in vital signs. The nurse should stay with the client and should continue to assess him or her while another nurse notifies the surgeon or the anesthesiologist.

7. A client is admitted for a total hip replacement. Past medical history includes diabetes mellitus type 2, a heart attack 5 years ago, and allergies to sulfa drugs. The client currently takes insulin on a sliding scale and celecoxib (Celebrex). Before administering the client's medications, which action by the nurse is most appropriate? a. Take the client's blood pressure in both arms. b. Call the physician to clarify the orders. c. Schedule a preoperative electrocardiogram. d. Review the client's laboratory values.

ANS: B Celebrex is a cyclooxygenase (COX)-2 inhibitor. These drugs are thought to cause serious adverse reactions such as myocardial infarction and renal problems. This client already has coronary artery disease and a past myocardial infarction, so the nurse should discuss the order with the physician before giving the medication. Reviewing laboratory results could indicate renal impairment, but taking the client's blood pressure and scheduling an electrocardiogram (ECG) would not take priority over discussion with the physician.

34. The nurse is instructing a client about the management of systemic sclerosis. Which statement indicates that the client requires additional teaching? a. "I will let my doctor know right away if I develop a fever." b. "Ice packs will help relieve the aching pain in my hips and knees." c. "I will wear mittens when I am in the freezer section of the grocery store." d. "I will apply a rich moisturizer to my skin every morning after my shower."

ANS: B Ice packs should not be used by clients with systemic sclerosis because the cold can trigger symptoms of Raynaud's phenomenon. The client should wear mittens whenever his or her hands are exposed to cold temperatures, and moisturizer should be applied daily. The client should notify the doctor if a fever develops.

3. The nurse is working with a client who will be taking 20 mg of prednisone daily for rheumatoid arthritis. Which precautions does the nurse give the client about taking this medication? a. "Take this medication at bedtime because it will make you sleepy." b. "Take calcium and vitamin D supplements daily." c. "Eat a high-fiber diet with lots of lean meats." d. "Wash your face twice a day with an antibacterial soap."

ANS: B Long-term steroid use is associated with many complications, including diabetes, infection, and osteoporosis, among others. The client should be instructed to take calcium and vitamin D supplements to help prevent osteoporosis. Prednisone does not cause constipation, so increased fiber would not be helpful. Prednisone should be taken in the morning because it may interfere with sleep if taken at bedtime. Washing the face with antibacterial soap may cause skin dryness and breakdown.

11. A client who has had bilateral total knee replacements is prescribed enoxaparin sodium (Lovenox) injections twice daily for the next 3 weeks. The client asks the nurse why she has to have the medication. What is the nurse's best response? a. "To prevent swelling within your new knee joints." b. "To prevent the formation of blood clots in your legs." c. "To prevent arthritis from developing in your new knee joints." d. "To prevent an infection from developing in your new knee joints."

ANS: B Lovenox is an anticoagulant that will help prevent formation of postoperative deep vein thrombosis (DVT). Lovenox does not decrease or prevent swelling, it does not prevent arthritis, and it is not an antibiotic.

24. The nurse is working in a primary care clinic and sees a young male client. The client is athletic and is well over 6 feet tall, with size 14 shoes. What diagnostic test does the nurse facilitate for the client? a. Coagulation studies b. Echocardiography c. Electromyelography d. Genetic testing

ANS: B Marfan syndrome is seen in athletic clients who are very tall and have large hands and feet. Echocardiography should be done for clients who may have Marfan syndrome to monitor for mitral valve prolapse and aortic aneurysm. Marfan disease has a genetic component, and genetic testing may be done, but the priority is monitoring the client for cardiac complications.

30. A female client with rheumatoid arthritis has taken Rheumatrex (methotrexate) for the past year to control her symptoms. The client comes to the clinic and tells the nurse that a home pregnancy test was positive. What is the nurse's best response? a. "You need to schedule a prenatal appointment with your obstetrician right away." b. "Stop taking Rheumatrex immediately. I'll tell the physician you are pregnant." c. "Continue taking the Rheumatrex, and increase the dose if you have a flare." d. "See a genetic counselor to determine whether your baby will have rheumatoid arthritis."

ANS: B Rheumatrex is highly teratogenic and should not be taken during pregnancy. A prenatal appointment should be made right away, but the first priority is to stop taking methotrexate. Genetic counseling is not appropriate because the counselor will not be able to determine whether the baby will develop rheumatoid arthritis.

25. The nurse is working in a clinic when a young male client presents with reports of pain with urination. The client wants testing for sexually transmitted diseases (STDs). The nurse notes that the client's eyes are red and inflamed. What question by the nurse is most important? a. "Do you have more than one sexual partner?" b. "Do you have any new joint pain?" c. "What eyedrops have you used for your red eyes?" d. "Are you allergic to any antibiotics?"

ANS: B The client has two symptoms of Reiter's syndrome (urethritis and conjunctivitis). The nurse should ask about joint pain because this is the third classic manifestation of this disease. All other questions are appropriate, but before treatment is started, the client needs an accurate diagnosis.

26. A client presents with painful, inflamed fingers with small, hard, yellow nodules that have a sandy yellow drainage. Which medication does the nurse prepare to administer to the client? a. Colchicine (Colasalide) b. Allopurinol (Zyloprim) c. Methotrexate (Rheumatrex) d. Aspirin

ANS: B The client is presenting with symptoms of chronic gout, and allopurinol would be the drug of choice to reduce uric acid levels. Colchicine is used to treat acute gout attacks. Methotrexate and aspirin are not used to treat chronic gout.

40. The nurse is working with a client who has severe rheumatoid arthritis in her hands. The client states that she is frustrated at mealtime because it is difficult for her to manage cups and silverware. What is the nurse's best response? a. "I'll have the nursing assistants set up your meal trays while you are in the hospital." b. "Let's see if the occupational therapist can provide you with some utensils that are easier for you to use." c. "I'll arrange for a home nursing assistant to help you with your meals after you are discharged from the hospital." d. "Let's see if the physical therapist can suggest some muscle strengthening exercises for you."

ANS: B The client wishes to be more independent at mealtimes; adaptive eating utensils from the occupational therapist will help her meet this goal. Muscle-strengthening exercises will not be as effective for the client's mealtime needs. The client wishes to remain as independent as possible, so a home nursing assistant should not be suggested.

43. The nurse is caring for an older adult client who has had a hip replacement 2 days previously. Which assessment finding is the best indicator that the client does not need pain medication at this time? a. The client received 2 pain pills 2 hours ago. b. The client states that she has no pain. c. The client is sleeping quietly. d. The client's vital signs are stable.

ANS: B The client's report of pain is the best indicator of pain level, rather than vital signs, sleeping, or time of last pain medication.

1. What interventions does the nurse recommend for a client who is to be discharged home following total hip replacement surgery? (Select all that apply.) a. Continuous passive motion machine b. Elevated toilet seat c. Walker d. Crutches e. TED hose f. Heating pad

ANS: B, C, E The client will be using a walker, because crutches are used only by younger clients. TED hose should be worn until the client regains full mobility and Coumadin is discontinued. A walker will be needed until the client regains full strength and is able to walk with full weight bearing on the operative side. Crutches are not used because they do not provide enough support for the client during ambulation and pose a risk for falls. Heating pads increase blood flow to the area and may increase pain. Ice packs should be used instead, as needed. Continuous passive motion machines are not used after hip surgery.

3. The nurse is teaching a client with rheumatoid arthritis (RA) about joint protection principles. What information does the nurse include? (Select all that apply.) a. Use smaller joints to rest the larger ones. b. Hold objects with two hands, not one. c. Sit most often in a reclining chair. d. Use assistive-adaptive devices. e. Bend at your knees to lift objects.

ANS: B, D, E Clients with RA should use large joints to protect smaller ones, should hold objects with two hands instead of one, should sit in chairs with straight backs, should not bend at the waist but rather bend the knees while keeping the back straight, and should use assistive-adaptive devices wherever possible.

12. The nurse is caring for a client who had right total knee replacement surgery 3 days ago. During the assessment, the nurse notes that the client's right lower leg is twice the size of the left. What is the nurse's priority intervention? a. Elevate the client's right leg. b. Apply antiembolism stockings. c. Assess the client's respiratory status. d. Check the client's pedal pulses.

ANS: C A common complication after total knee replacement (TKR) is the formation of a thrombus below the surgical site. This complication can lead to a pulmonary embolus and can be life threatening. Before notifying the surgeon or the emergency team, assess the client's pulmonary status to determine whether he or she has any manifestations of an embolus. The client's leg may be elevated and pedal pulses palpated, but respiratory assessment must be done first. TED hose should not be applied to a leg with suspected deep vein thrombosis (DVT).

5. A client returns to the medical-surgical unit after a total hip replacement with a large wedge-shaped pillow between his legs. The client's daughter asks the nurse why the pillow is in place. What is the nurse's best response? a. "It will help prevent bedsores from developing." b. "It will help prevent nerve damage and foot drop." c. "It will keep the new hip from becoming dislocated." d. "It will prevent climbing out of bed if he becomes confused."

ANS: C Adduction of the operative leg beyond the midline could dislocate the new hip. The wedge pillow will help prevent this from happening. The wedge will not prevent bedsores from developing because it does not prevent pressure. The pillow will not prevent foot drop, because it is placed between the legs. The pillow is not a restraining device, and it will not prevent the client from climbing out of bed.

22. The nurse has taught a client with lupus about skin protection in the clinic. Later, the nurse sees the client at an outdoor music festival. Which observation by the nurse indicates that the client requires further instruction? a. Client is wearing a thin, long-sleeved shirt. b. Client is wearing a hat with a full brim. c. Client is discussing her new perm. d. Client is seen applying sunscreen twice.

ANS: C Alopecia is common; the client should use gentle shampoo and avoid any harsh chemical treatments, such as a permanent wave. The other observations show good skin protection practices by the client.

32. Which statement by a client indicates that additional teaching is needed in the management of fibromyalgia? a. "I will switch to decaffeinated coffee in the mornings." b. "Water aerobics classes will be a good form of exercise." c. "Limiting my physical activity will reduce my fatigue." d. "I will take my sertraline (Zoloft) right before I go to bed."

ANS: C Clients with fibromyalgia should be encouraged to exercise regularly, particularly performing activities that are low impact. Sleep disturbances are common in fibromyalgia, and anything that interferes with sleep, such as caffeine, should be avoided. Zoloft can cause drowsiness and should be taken daily at bedtime.

10. The home care nurse is making a follow-up visit to a client who had total hip replacement surgery 2 weeks ago. Which client statement indicates a need for clarification regarding postoperative routine? a. "My daughter helps me put on my elastic TED (thromboembolic deterrent) hose every day." b. "I take 200 mg of Motrin (ibuprofen) at bedtime so that I can sleep." c. "Now that my hip doesn't hurt, I can cross my legs like a lady again." d. "Each day, I try to increase my walking time by at least 10 minutes."

ANS: C Crossing the legs beyond midline can dislocate the new hip joint and should be avoided at all times. The other statements demonstrate correct behavior and understanding.

29. The nurse is caring for a pregnant client who is taking Humira (adalimumab) to control symptoms of rheumatoid arthritis. The client mentions the pain and inconvenience of the subcutaneous injections and asks, "While I'm pregnant, can I take this drug by mouth instead?" What is the nurse's best response? a. "I will ask the physician to write a prescription for you today." b. "Humira takes much longer to work when it is given orally." c. "Humira can be given only by subcutaneous injection." d. "You can switch from Humira to oral leflunomide (Arava)."

ANS: C Humira is given by subcutaneous injection only. Arava causes birth defects; clients taking it must be on strict birth control and must inform their health care providers if pregnancy occurs.

17. The nurse is teaching a client how to reduce the pain that she often experiences with fibromyalgia. Which statement does the nurse include in the teaching? a. "Wear gloves outdoors in cooler temperatures." b. "Avoid exercising when your muscles are sore." c. "Make sure that you get enough sleep every night." d. "Stay out of the sun as much as possible."

ANS: C In many clients, the pain of fibromyalgia occurs as a direct response to sleep deprivation. Encouraging the client to get sufficient sleep every night can drastically reduce the amount of pain experienced. Wearing gloves will not decrease the pain of fibromyalgia, but it may help a disease such as Raynaud's phenomenon. Weight-bearing activities should not increase pain in a client with fibromyalgia. Similarly, sun exposure has not been identified as a causative pain factor.

20. The school nurse is working with a group of high school students who will be going on a field trip to a nature center. Which student is at highest risk for a tick bite? a. Male student with a beard and a baseball cap b. Female student with long hair pulled back in a ponytail c. Male student wearing a long-sleeved shirt and shorts d. Female student who is wearing scented hand lotion

ANS: C Long pants should be worn and tucked into socks or boots to help prevent tick bites. Facial hair, hats, ponytails, and scented body products do not increase the risk for tick bites.

19. The nurse provides discharge teaching for a client to prevent a new attack of gout. Which statement by the client indicates that additional teaching is required? a. "I will keep a food and symptom diary for a few weeks." b. "If I get a headache, I will take Tylenol instead of aspirin." c. "I hate to start limiting my fluid intake so much!" d. "Citrus juices and milk may keep me from having kidney stones."

ANS: C Nutritional therapy for gout is controversial; however, clients do need to increase their fluid intake to prevent kidney stones. Certain foods may precipitate an acute attack, so clients should learn to determine which foods trigger their gout. Aspirin is well known to trigger gout attacks. Increasing the intake of alkaline ash foods such as citrus juices and milk might prevent the formation of kidney stones.

23. A client with diagnosed osteoarthritis comes to the clinic reporting a low-grade fever, fatigue, and bilateral joint pain. What action by the nurse is most appropriate? a. Assess the client for a systemic infection. b. Discuss increasing the dose of anti-arthritis drugs. c. Prepare the client for a laboratory draw for rheumatoid factor. d. Teach the client joint protection activities.

ANS: C Osteoarthritis is generally a unilateral disease. The manifestations that this client exhibits are more consistent with rheumatoid arthritis, so the nurse will prepare the client for a blood draw. The nurse may need to teach joint protection measures, but an accurate diagnosis is most important.

44. The nurse is caring for a client who has a history of severe rheumatoid arthritis. The client becomes combative and abusive to the staff when she is unable to perform personal care independently. What is the best statement the nurse can make to the client at this time? a. "I will have to restrain your hands if you cannot keep them to yourself." b. "I will ask your doctor for a psychiatrist to talk to you about anger management." c. "You seem frustrated. Would you like to try to dress again in a few minutes?" d. "Would you like me to get an order for medication to help you settle down?"

ANS: C The client is acting out her frustration over her chronic illness and loss of use of her hands. The nurse should acknowledge this frustration. Allowing the client to make decisions regarding care will help the client regain some sense of control and will help improve self-esteem. Requesting sedation, suggesting psychiatric therapy, or threatening use of restraints is not appropriate, because the client is expressing frustration over the situation.

42. The nurse is caring for an older adult client who has fallen and fractured her hip. The client will have hip replacement surgery followed by extensive rehabilitation. The client confides in the nurse, "I feel like I don't have any control over anything anymore now that I am old." What is the nurse's best response? a. "I'll make sure that the physical and occupational therapists see you after surgery to help get your strength back." b. "It's normal to feel this way, but hopefully you will be back on your feet after a stay in rehab." c. "It's important to control what you can right now, like making out your menu every day and working with the therapists." d. "I sense that you are feeling depressed about the situation. I will ask the doctor to prescribe an antidepressant for you."

ANS: C The nurse should support the client's self-esteem and increase feelings of competency by encouraging activities that assist in maintaining some degree of control, such as participation in decision making and performance of tasks that he or she can manage. The nurse should provide immediate control options for the client, rather than waiting until after rehabilitation. The client's desire for control does not indicate depression, so an antidepressant is not indicated. Therapy referrals are appropriate but do not address the client's desire for control.

38. A nurse is caring for a client who has had rheumatoid arthritis (RA) for 5 years. Which laboratory value requires the most immediate intervention by the nurse? a. White blood cell count (WBC), 3800/mm3 b. Hemoglobin (Hg), 10.6 g/dL c. Blood urea nitrogen (BUN), 16 mg/dL d. Creatinine, 3.2 mg/dL

ANS: D Clients with RA usually have pancytopenia, or a decrease in all cell types. WBC and hemoglobin are low, consistent with this condition. BUN is normal. Creatinine is very high; this indicates renal disease. This client may have renal consequences of his or her RA, which should be investigated.

16. A client is suspected to have rheumatoid arthritis. Which manifestations does the nurse assess this client carefully for? a. Crepitus when the client moves the shoulders b. Numbness and tingling in the client's fingers c. Client has cool feet, with weak pedal pulses d. Low-grade fever, fatigue, anorexia with weight loss

ANS: D Low-grade fever is common with rheumatoid arthritis because of the inflammatory response. Fatigue, anorexia, and weight loss are also common symptoms. Impaired neurologic status, popping sounds with range of motion (ROM), and poor circulation are not common symptoms of rheumatoid arthritis.

31. The nurse is instructing a client about management of discoid lupus erythematosus (DLE). Which statement indicates that the client requires additional teaching? a. "I will be sure to apply sunscreen whenever I am outside." b. "I will apply small amounts of the steroid cream to my face twice a day." c. "I will take Plaquenil (hydroxychloroquine sulfate) with breakfast each morning." d. "Steroids weaken the immune system, so I will wash my hands frequently."

ANS: D Steroid creams used for the treatment of discoid lupus will not weaken the immune system because they should be applied in small amounts to affected areas. The client will be more sensitive to sun exposure while using the steroid cream, so sunscreen should be used whenever the client goes outside. The client should use only small amounts of the cream on her face. Plaquenil should be taken with meals or a glass of milk.

39. The nurse is caring for an older adult client who will be discharged after being hospitalized for a total hip replacement. Which statement indicates that arrangements may have to be made to have the client's medications supervised at home? a. "I will take my Coumadin pill every day just before the evening news." b. "My wife takes iron too, so we will take our pills together every morning." c. "I prepare all my pills for the week and will place them in a labeled medi-set." d. "If my legs get swollen, I will take an extra Coumadin pill that day."

ANS: D Warfarin (Coumadin) is an anticoagulant prescribed to prevent venous thromboembolism after joint replacement surgery. It is not used for edema. The other statements show that the client has an appropriate plan for self-administration of his medications.