Chapter 39: Assessment and Management of Patients With Rheumatic Disorders

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis? "My legs feel weak." "My finger joints are oddly shaped." "I have pain in my hands." "I have trouble with my balance."

Correct response: "My finger joints are oddly shaped." Explanation: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? A. "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B. "OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints." C. "OA affects joints on both sides of the body. RA is usually unilateral." D. "OA is more common in women. RA is more common in men."

Correct response: "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Explanation: OA is a degenerative arthritis, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. OA may occur in one hip or knee and not the other, whereas RA commonly affects the same joints bilaterally. RA is more common in women; OA affects both sexes equally. Aging is the risk factor most strongly correlated with OA.

A client with osteoarthritis tells the nurse she is concerned that the disease will prevent her from doing her chores. Which suggestion should the nurse offer?

Correct response: "Pace yourself and rest frequently, especially after activities." Explanation: A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace herself during daily activities. Telling the client to do her chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace herself and take frequent rests rather than doing all chores at once.

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain? Acupuncture An exercise routine that includes range-of-motion (ROM) exercises Heat therapy and nonsteroidal anti-inflammatory medications (NSAIDs) Cold therapy

Correct response: An exercise routine that includes range-of-motion (ROM) exercises Explanation: Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain.

What is the priority intervention for a patient who has been admitted repeatedly with attacks of gout?

Correct response: Assess dietary diet and activity at home Explanation: Patients with gout need teaching about diet restrictions in order to prevent repeated attacks. Foods high in purine need to be avoided, and alcohol intake has to be limited. Stressful activities should also be avoided. The nurse should assess to see what is stimulating the repeated attacks of gout. The other interventions are not appropriate for a patient with this problem.

The nurse is educating a patient about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms they should report. Which COX-2 inhibitor is the nurse educating the patient about? Ibuprofen (Motrin) Celecoxib (Celebrex) Piroxicam (Feldene) Tolmetin sodium (Tolectin)

Correct response: Celecoxib (Celebrex) Explanation: The COX-2 inhibitor celecoxib (Celebrex) is associated with an increased risk of cardiovascular events, including myocardial infarction and stroke.

A client is receiving treatment for an acute episode of gout with colchicine. The nurse is administering the medication every 2 hours. What should the nurse be sure the client communicates so that the drug can be temporarily stopped? Select all that apply.

Correct response: Diarrhea Intestinal cramping Nausea and vomiting Explanation: Colchicine is administered every 1 or 2 hours until the pain subsides or nausea, vomiting, intestinal cramping, and diarrhea develop. When one or more of these symptoms occurs, the drug should be stopped temporarily. Tingling in the arms and increase in pain are not normal adverse reactions that are seen with this drug.

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. Which of the following would the nurse expect to find? Increased red blood cell count Increased C4 complement Elevated erythrocyte sedimentation rate Increased albumin levels

Correct response: Elevated erythrocyte sedimentation rate Explanation: The erythrocyte sedimentation rate (ESR) may be elevated, particularly as the disease progresses. ESR shows inflammation associated with RA. Red blood cell count and C4 complement component are decreased. Serum protein electrophoresis may disclose increased levels of gamma and alpha globulin but decreased albumin.

Which findings best correlate with a diagnosis of osteoarthritis? A.Joint stiffness that decreases with activity B.Erythema and edema over the affected joint C.Anorexia and weight loss D.Fever and malaise

Correct response: Joint stiffness that decreases with activity Explanation: A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that decreases with activity and movement. Erythema and edema over the affected joint, anorexia, weight loss, and fever and malaise are associated with rheumatoid arthritis, a more severe and destructive form of arthritis.

A nursing student asks the instructor how to identify rheumatoid nodules in a client with rheumatoid arthritis. Which of the following characteristics would the instructor include? Tender to touch Reddened Nonmovable Located over bony prominence

Correct response: Located over bony prominence Explanation: Rheumatoid nodules usually are nontender, movable, and evident over bony prominences, such as the elbow or the base of the spine. They are not reddened.

Which of the following would the nurse most commonly assess in a client with ankylosing spondylitis? Low back pain Increased urine output Red, butterfly-shaped facial rash Patchy hair loss on the scalp

Correct response: Low back pain Explanation: The most common symptoms of ankylosing spondylitis are low back pain and stiffness. A red, butterfly-shaped rash on the face and a patchy loss of hair are the associated with systemic lupus erythematosus. Ankylosing spondylitis does not affect urine output.

A client with rheumatoid arthritis has experienced increasing pain and progressing inflammation of the hands and feet. What would be the expected goal of the likely prescribed treatment regimen? A.Minimizing damage B. Eradicating pain C.Eliminating deformities D.Promoting sleep

Correct response: Minimizing damage Explanation: Although RA cannot be cured, much can be done to minimize damage. Treatment goals include decreasing joint inflammation before bony ankylosis occurs, relieving discomfort, preventing or correcting deformities, and maintaining or restoring function of affected structures. Early treatment leads to the best results.

A patient is suspected of having myositis. The nurse prepares the patient for what procedure that will confirm the diagnosis? Bone scan Computed tomography (CT) Magnetic resonance imaging (MRI) Muscle biopsy

Correct response: Muscle biopsy Explanation: As with other diffuse connective tissue disorders, no single test confirms polymyositis. An electromyogram is performed to rule out degenerative muscle disease. A muscle biopsy may reveal inflammatory infiltrate in the tissue. Serum studies indicate increased muscle enzyme activity.

Nursing assessment for tinnitus, gastric intolerance, and bleeding is important for patient who take which class of medications for a rheumatic disease? Salicylates COX-2 inhibitors Immunosuppressive Antimalarials

Correct response: Salicylates Explanation: Salicylates have anti-inflammatory, analgesic, and antipyretic actions. They should be given with meals to prevent gastric irritation.

A patient has a serum study that is positive for the rheumatoid factor. What does the nurse understand is the significance of this test result?

Correct response: Suggestive of RA Explanation: Rheumatoid factor is present in about 80% of patients with RA, but its presence alone is not diagnostic of RA, and its absence does not rule out the diagnosis.

A nurse is assessing a client with possible osteoarthritis. The most significant risk factor for primary osteoarthritis is: congenital deformity. age. trauma. obesity.

Correct response: age. Explanation: Age is the most significant risk factor for developing primary osteoarthritis. Development of primary osteoarthritis is influenced by genetic, metabolic, mechanical, and chemical factors. Secondary osteoarthritis usually has identifiable precipitating events such as trauma.

Which of the following points should be included in the medication-teaching plan for a patient taking adalimumab (Humira)? A.The medication is administered IM. B.The patient should continue taking the medication if fever occurs. C.The medication is given at room temperature. D.It is important to monitor for injection site reactions.

It is important to monitor for injection site reactions. Explanation: It is important to monitor for injection site reactions. The medication is injected subcutaneously and must be refrigerated. The medication should be withheld if fever occurs.

Which of the following terms refers to fixation or immobility of a joint? Hemarthrosis Diarthrodial Arthroplasty Ankylosis

Correct response: Ankylosis Explanation: Ankylosis may result from disease or scarring due to trauma. Hemarthrosis refers to bleeding into the joint. Diarthrodial refers to a joint with two free moving parts. Arthroplasty refers to replacement of a joint.

A nurse practitioner is managing the care of a patient who has gout. Choose the medication that she would prescribe as the drug of choice to prevent tophi formation and promote tophi regression. Benemid Anturane Uloric Zyloprim

Correct response: Zyloprim Explanation: Allopurinol (Zyloprim), a xanthine oxidase inhibitor, is considered the drug of choice for preventing the precipitation of an attack, preventing tophi formation, and promoting the regression of existing tophi. Uricosuric agents, such as probenecid (Benemid), correct hyperuricemia and dissolve deposited urate.

Which of the following would be consistent with the diagnosis of rheumatoid arthritis? Decreased ESR Cloudy synovial fluid Increased red blood cell count Increased C4 complement component

Correct response: Cloudy synovial fluid Explanation: In a patient with rheumatoid arthritis, Arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement.

After teaching a group of students about systemic lupus erythematosus, the instructor determines that the teaching was successful when the students state which of the following?

Correct response: The belief is that it is an autoimmune disorder with an unknown trigger. Explanation: Systemic lupus erythematosus is believed to be an autoimmune disorder but the triggering mechanism is not known. The disorder is more common in women than in men, most with the disorder in the 3rd or 4th decade of life. The disease is considered the "great imitator" because the clinical signs resemble many other conditions. SLE is a diffuse connective tissue disease that affects multiple body systems. Sunlight tends to exacerbate the disease. Because fatigue is a major issue, allow for adequate rest, along with regular activity to promote mobility and prevent joint stiffness. Maintain a well-balanced diet and increase fluid intake to raise energy levels and promote tissue healing.

Which of the following is an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage? Subchondral bone Pannus Joint effusion Tophi

Correct response: Tophi Explanation: Tophi, when problematic, are surgically excised. Subchondral bone refers to a bony plate that supports the articular cartilage. Pannus refers to newly formed synovial tissue infiltrated with inflammatory cells. Joint effusion refers to the escape of fluid from the blood vessels or lymphatic vessels into the joint cavity.

Which of the following newer pharmacological therapies, used for the treatment of osteoarthritis, is thought to improve cartilage function and retard degradation as well as have some anti-inflammatory effects? Glucosamine Chondroitin Viscosupplementation Capsaicin

Correct response: Viscosupplementation Explanation: Viscosupplementation, the intra-articular injection of hyaluronic acid, is thought to improve cartilage function and retard degradation. It may also have some anti-inflammatory effects. Glucosamine and chondroitin are thought to improve tissue function and retard breakdown of cartilage. Capsaicin is a topical analgesic.

A nurse is poviding care for a client with progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis? A.Risk for impaired skin integrity B.Constipation C.Ineffective thermoregulation D.Risk for imbalanced nutrition: More than body requirements

Correct response: Risk for impaired skin integrity Explanation: Progressive systemic sclerosis is a connective tissue disease characterized by fibrosis and degenerative changes of the skin, synovial membranes, and digital arteries. Therefore, the nurse is most likely to formulate a nursing diagnosis of Risk for impaired skin integrity. Because clients with the disease are prone to diarrhea from GI tract hypermotility (caused by pathologic changes), Constipation is an unlikely nursing diagnosis. Progressive systemic sclerosis doesn't cause Ineffective thermoregulation. GI hypermotility may lead to malabsorption, and esophageal dysfunction may cause dysphagia; these conditions put the client with the disease at risk for inadequate nutrition, making Risk for imbalanced nutrition: More than body requirements an improbable nursing diagnosis.

The nurse teaches the patient that the presence of crystals in his or her synovial fluid obtained from an arthrocentesis confirms which disease process? Gout Infection Inflammation Degeneration

Correct response: Gout Explanation: The presence of crystals is indicative of gout, and the presence of bacteria is indicative of infective arthritis. Gout is caused by hyperuricemia (increased serum uric acid).

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan? "Exposure to sunlight will help control skin rashes." "There are no activity limitations between flare-ups." "Monitor your body temperature." "Corticosteroids may be stopped when symptoms are relieved."

Correct response: "Monitor your body temperature." Explanation: The nurse should instruct the client to monitor body temperature. Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation.

Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)? A. Nonsteroidal anti-inflammatory drugs (NSAIDs) B .Disease-modifying antirheumatic drugs (DMARDS) C. Tumor necrosis factor (TNF) blockers D. Glucocorticoids

Correct response: Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: In most patients NSAIDs usually are the first choice in the treatment of RA. The use of traditional NSAIDs and salicylates inhibit the production of prostaglandins and provide anti-inflammatory effects as well as analgesic. In RA, if joint symptoms persist despite use of NSAIDs, the second major drug group known as DMARDs is initiated early in the disease. TNF blockers interfere with the action of tumor necrosis factor (TNF). Oral glucocorticoids, such as prednisone and prednisolone, are indicated for patients with generalized symptoms.

Which of the following is the leading cause of disability and pain in the elderly? A. Osteoarthritis B.Rheumatoid arthritis (RA) C.Systemic lupus erythematous (SLE) D.Scleroderma

Correct response: Osteoarthritis Explanation: Osteoarthritis is the leading cause of disability and pain in the elderly. RA, SLE, and scleroderma are not leading causes of disability and pain in the elderly. A client with osteoarthritis has increased stiffness in the morning upon awakening. Exercise should be scheduled at least 1 hour after awakening. Exercising in the evening interferes with the client's ability to rest at bedtime.

Nursing care for the patient with fibromyalgia should be guided by what assumption?

Correct response: Patients with fibromyalgia may feel as if their symptoms are not taken seriously. Explanation: Because patients present with widespread symptoms that are often vague in nature, health care providers may misdiagnose patients. Patients feel as though people are not listening to them. Nurses need to provide support and encouragement. Symptoms of disease vary from patient to patient, and respond to different treatments. Patients do not lose their ability to walk.

Which diagnostic study is decreased in patient diagnosed with rheumatoid arthritis? ESR Red blood cell count Uric acid Creatinine

Correct response: Red blood cell count Explanation: There is a decreased red blood cell count in patients diagnosed with rheumatic diseases. EDR increases inflammatory connective tissue disease. Uric acid is increased in gout. Increased creatinine may indicate renal damage in SLE, scleroderma, and polyarteritis.