Chapter 39
A nurse is providing care for a patient who has a rheumatic disorder. The nurse's comprehensive assessment includes the patient's mood, behavior, LOC, and neurologic status. What is this patient's most likely diagnosis? A) Osteoarthritis (OA) B) Systemic lupus erythematosus (SLE) C) Rheumatoid arthritis (RA) D) Gout
B) Systemic lupus erythematosus (SLE) SLE has a high degree of neurologic involvement, and can result in central nervous system changes. The patient and family members are asked about any behavioral changes, including manifestations of neurosis or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central nervous system manifestations. OA, RA, and gout lack this dimension.
A nurse is creating a teaching plan for a patient who has a recent diagnosis of scleroderma. What topics should the nurse address during health education? Select all that apply. A) Surgical treatment options B) The importance of weight loss C) Managing Raynaud's-type symptoms D) Smoking cessation E) The importance of vigilant skin care
C) Managing Raynaud's-type symptoms D) Smoking cessation E) The importance of vigilant skin care Patient teaching for the patient with scleroderma focuses on management of Raynaud's phenomenon, smoking cessation, and meticulous skin care. Surgical treatment options do not exist and weight loss is not a central concern.
A client is experiencing symptoms that are suspected to be related to systemic lupus erythematosus. What cutaneous symptom occurs in about 50% of clients affected by this disease? - Fluid-filled vesicles clustered on the cheeks, chin, and forehead - Pustules scattered on the chest and back - Butterfly-shaped rash on the face over the bridge of the nose and cheeks - Diffuse purplish lesions on the trunk
Correct response: Butterfly-shaped rash on the face over the bridge of the nose and cheeks Explanation: A prominent sign for about half of the clients with SLE is a red, butterfly-shaped rash known as malar rash, on the face over the bridge of the nose and the cheeks. The word lupus means "wolf." The term may have been used as a description for the facial rash that, to some, resembled the mask of reddish-brown fur on a wolf. The other choices are not routinely seen with SLE.
10) ** A nurse is assessing a client with possible osteoarthritis. What is the most significant risk factor for primary osteoarthritis? 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.
A 44-year-old patient has been seen in the clinic for suspected rheumatic disorder. She is to undergo a procedure to retrieve synovial fluid from her knee for a definitive diagnosis. The nurse knows that which of the following procedures will be involved? - Angiography - Arthrocentesis - Myelography - Paracentesis
Correct response: Arthrocentesis Explanation: Arthrocentesis (needle aspiration of synovial fluid) may be performed not only to obtain a sample of synovial fluid for analysis, but also to relieve pain caused by pressure of increased fluid volume, usually in the knee or shoulder. Angiography is an X-ray study of circulation with a contrast agent injected into a selected artery. Myelography is an X-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Paracentesis is removal of fluid (ascites) from the peritoneal cavity through a small surgical incision or puncture made through the abdominal wall under sterile conditions.
A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern? Butterfly rash Papular rash Pustular rash Bull's eye rash
Correct response: Butterfly rash Explanation: In the classic lupus rash, lesions appear on the cheeks and the bridge of the nose, creating a characteristic butterfly pattern. The rash may vary in severity from malar erythema to discoid lesions (plaque). Papular and pustular rashes aren't associated with SLE. The bull's eye rash is classic in client's with Lyme disease.
A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse would include which of the following as a causative agent in gout? - Hypouricemia - Thrombocytopenia - Hypocalcemia - Hyperuricemia
Correct response: Hyperuricemia Explanation: Oversecretion of uric acid or a renal defect resulting in decreased excretion of uric acid, or a combination of both occurs in gout. Hyperuricemia occurs. Thrombocytopenia is indicative of systemic lupus erythematosus. Hypercalcemia can cause kidney stones related to gout.
A 36-year-old woman has been experiencing debilitating pain and fatigue for several months and has sought care on numerous occasions from several different care providers. She is now being assessed for fibromyalgia. The patient tells the clinic nurse that it is an incredible relief to have a possible diagnosis, stating, "I felt for so long that absolutely no one was taking me seriously." The nurse should recognize that this statement represents an improvement in which of the following nursing diagnoses? - Ineffective therapeutic regimen management - Anxiety - Ineffective coping - Powerlessness
Correct response: Powerlessness Explanation: The patient's repeated complaints that failed to result in adequate follow-up are suggestive of a feeling of powerlessness. The patient's statement does not indicate that she was coping ineffectively or neglecting her health. Anxiety likely accompanied the woman's experience in the health care system, but her statement most clearly suggests powerlessness.
A middle-aged female patient has received a diagnosis of scleroderma with a chronic course and has been informed by her primary care provider that the disease has no cure. When considering the characteristic signs and symptoms of scleroderma, what nursing diagnosis should the nurse prioritize? - Risk for disturbed body image related to the integumentary effects of scleroderma - Risk for spiritual distress related to the clinical course of scleroderma - Risk for chronic pain related to neurological effects of scleroderma - Risk for acute confusion related to neurological effects of scleroderma
Correct response: Risk for disturbed body image related to the integumentary effects of scleroderma Explanation: Scleroderma is associated with profound sclerotic changes in the skin, contractures in the fingers, and color changes or ulcerations in the fingertips due to poor circulation. The patient's facial appearance changes and creates a risk of disturbed body image. Pain and confusion are not commonly associated with the disease. Spiritual distress is a realistic possibility but is likely not as universally prevalent as disturbed body image in patients with scleroderma.
Which intervention should the nurse implement to manage pain for the client with rheumatoid arthritis? Select all that apply. - Support joints with splints and pillows. - Provide diversional activities. - Assist the client to develop a sleep routine. - Provide assistive devices for self-feeding. - Provide opportunities for the client to verbalize feelings.
Correct response: Support joints with splints and pillows. Provide diversional activities. Provide opportunities for the client to verbalize feelings. Explanation: To manage pain, the nurse maintains normal alignment of extremities as much as possible by supporting the joints with splints and pillows. Diversional activities distract the client's focus from the pain. Providing opportunities for the client to verbalize feelings facilitates coping with pain. Assistive devices for self-feeding help the client meet nutritional needs independently. Assisting the client to develop a sleep routine promotes rest and minimizes fatigue.
19) ** The nurse is caring for a client who is being treated for fibromyalgia. What intervention will best assist the client to restore normal sleep patterns? - Administering opioids at bed time - Increasing activity during the day - Range-of-motion exercise before sleeping - Tricyclic antidepressants
Correct response: Tricyclic antidepressants Explanation: Tricyclic antidepressants and sleep hygiene measures are used to improve or restore normal sleep patterns in clients with fibromyalgia. Increasing activity during the day or using range-of-motion exercises will not increase the client's ability to sleep. Narcotics are generally not needed for pain control with this disorder.
A nurse's plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals? A) Maximize range of motion while minimizing exertion B) Increase joint size and strength C) Limit energy output in order to preserve strength for healing D) Preserve and increase range of motion while limiting joint stress
D) Preserve and increase range of motion while limiting joint stress Exercise is vital to the management of rheumatic disorders. Goals should be preserving and promoting mobility and joint function while limiting stress on the joint and possible damage. Cardiovascular exertion should remain within age-based limits and individual ability, but it is not a goal to minimize exertion. Increasing joint size is not a valid goal.
A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid arthritis (RA). On what aspect of the patient's health should the nurse focus most closely during the visit? A) The patient's understanding of rheumatoid arthritis B) The patient's risk for cardiopulmonary complications C) The patient's social support system D) The patient's functional status
D) The patient's functional status The patient's functional status is a central focus of home assessment of the patient with RA. The nurse may also address the patient's understanding of the disease, complications, and social support, but the patient's level of function and quality of life is a primary concern.
The nurse is preparing to care for a patient who has scleroderma. The nurse refers to resources that describe CREST syndrome. Which of the following is a component of CREST syndrome? A) Raynaud's phenomenon B) Thyroid dysfunction C) Esophageal varices D) Osteopenia
A) Raynaud's phenomenon The R in CREST stands for Raynaud's phenomenon. Thyroid dysfunction, esophageal varices, and osteopenia are not associated with scleroderma. Cutaneous Symptoms of Scleroderma Be alert for the CREST symptoms: C - Calcinosis (calcium deposits in the tissues) R - Raynaud phenomenon (spasm of blood vessels in response to cold or stress) E - Esophageal dysfunction (acid reflux and decrease in mobility of esophagus) S- Sclerodactyly (thickening and tightening of skin on fingers and hands) T - Telangiectasia (capillary dilation that forms vascular red marks on surface of skin)
A 60-year-old man with several health problems and a history of increasing joint stiffness over the past several months is being assessed for the presence of rheumatic diseases. Which of the following laboratory findings is most clearly suggestive of an inflammatory process? -Erythrocyte sedimentation rate (ESR) of 22 mm/hr (normal 0 to 20 mm/hr) -Ammonia level of 55 µmol/L (normal 12 to 55 µmol/L) -Lactic acid of 2.0 mEq/L (normal 0.6 to 1.8 mEq/L) -Albumin 3.3 g/dL (normal 3.5 to 5.0 g/dL)
Answer - ESR of 22 Explain: Westergren method - Men, 0-15 mm/hr, over 50 years of age: 0-20 mm/hr -Women, 0-20 mm/hr, over 50 years of age: 0-30 mm/hr -Usually increase is seen in inflammatory connective tissue diseases (e.g., RA, SLE, scleroderma), gout, can be seen in elderly -An increase indicates rising inflammation; the higher the ESR, the greater the inflammatory activity
A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the patient appears to have lost some of her ability to function since her last office visit. Which of the following is the most appropriate action? A) Arrange a family meeting in order to explore assisted living options. B) Refer the patient to a support group. C) Arrange for the patient to be assessed in her home environment. D) Refer the patient to social work.
C) Arrange for the patient to be assessed in her home environment. Assessment in the patient's home setting can often reveal more meaningful data than an assessment in the health care setting. There is no indication that assisted living is a pressing need or that the patient would benefit from social work or a support group.
A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse should describe which of the following? A) Autoimmune processes in the joints B) Chronic metabolic acidosis C) Increased uric acid levels D) Unstable serum calcium levels
C) Increased uric acid levels Gout is caused by hyperuricemia (increased serum uric acid). Gout is not categorized as an autoimmune disease and it does not result from metabolic acidosis or unstable serum calcium levels.
A nurse is educating a patient with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make? A) Ensuring adequate rest B) Limiting exposure to sunlight C) Limiting intake of alcohol D) Smoking cessation
C) Limiting intake of alcohol Alcohol and red meat can precipitate an acute exacerbation of gout. Each of the other listed actions is consistent with good health, but none directly addresses the factors that exacerbate gout.
Following an extensive diagnostic workup, a 40-year-old woman's complaints of fatigue and muscle pain have been attributed to systemic lupus erythematosus (SLE).When performing health education with this patient, what should the nurse emphasize? - "It's best to keep your activity level as low as possible, to preserve energy and promote healing." - "You'll need to be very conscientious with your diet and avoid fats, salt, and sugar." - "It's important to limit your exposure to sunlight and to use a good sunscreen." - "Many patients who are diagnosed in mid-life recover from SLE in a few years."
Correct response: "It's important to limit your exposure to sunlight and to use a good sunscreen." Explanation: The patient with SLE should avoid excessive sun exposure and use sunscreen. A healthy diet is beneficial but is not specific to the management of SLE. Treatment focuses on symptom relief and management, not cure. It is incorrect to recommend activity limitation as a management strategy, although some form of activity management may be necessary.
The nurse is caring for a 69-year-old patient with a history of osteoarthritis (OA) who has just been admitted to the medical unit. The patient asks the nurse what the difference is between OA and rheumatoid arthritis (RA). What is the best response by the nurse? - "OA affects joints on both sides of the body. RA is usually unilateral." - "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." - " OA and RA are very similar. OA affects the smaller joints, and RA affects the larger, weight-bearing joints." - "OA is more common in women. RA is more common in men."
Correct response: "OA is considered 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, whereas OA affects both sexes equally.
2) ** A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse? - "The doctor could prescribe anti-inflammatory drugs." - "The doctor could prescribe antipyretic drugs." - "The doctor could prescribe antihypertensive drugs." - "The doctor could prescribe antineoplastic drugs."
Correct response: "The doctor could prescribe anti-inflammatory drugs." Explanation: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Antipyretic and antihypertensive drugs are not prescribed for autoimmune diseases. An antineoplastic drug is not ordered for an autoimmune disorder until it is in its late stages and uncontrolled by the first-line drugs.
The nurse is assessing a patient with a diagnosis of scleroderma. What clinical manifestations of scleroderma does the nurse assess? (Select all that apply.) - Productive cough - Butterfly-shaped rash on the face - Dyspnea owing to fibrotic cardiac tissue - Decreased ventilation owing to lung scarring - Dysphagia owing to hardening of the esophagus
Correct response: Decreased ventilation owing to lung scarring Dysphagia owing to hardening of the esophagus Dyspnea owing to fibrotic cardiac tissue Explanation: The changes within the body, although not visible directly, are vastly more important than the visible changes. The left ventricle of the heart is involved, resulting in heart failure. The esophagus hardens, interfering with swallowing. The lungs become scarred, impeding respiration. Digestive disturbances occur because of hardening (sclerosing) of the intestinal mucosa. Progressive kidney failure may occur.
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. - Nausea and vomiting - Increase in pain in the affected extremity - Diarrhea - Intestinal cramping - Tingling in the arms
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.
A 57-year-old woman was diagnosed with osteoarthritis (OA) by her primary care provider several months ago and claims that she is achieving acceptable control of her symptoms by taking acetaminophen several times daily. The nurse should perform further assessment to ensure that the patient is doing which of the following? - Taking her acetaminophen with food - Not exceeding 2,000 mg of acetaminophen in any 24-hour period - Drinking sufficient amounts of fluids - Not exceeding three doses per day
Correct response: Drinking sufficient amounts of fluids Explanation: In OA, the initial analgesic therapy is acetaminophen in doses of up to 1,000 mg every 6 hours, with the daily dose not to exceed 4,000 mg/day. Adequate intake of water, at least 2,000 mL/day, is encouraged to promote excretion of the drug. It is not necessary to take the drug with food.
A nurse who works in a long-term care setting is responsible for the care of numerous older adult residents who have osteoarthritis (OA). When performing health education to promote activities of daily living, the nurse should recommend which of the following? - Activity limitation to preserve energy - A treatment plan that is centered around dietary supplements - Efforts to reduce body weight if the individual is obese - Weight-bearing exercise as tolerated
Correct response: Efforts to reduce body weight if the individual is obese Explanation: Nursing interventions for OA mainly center around rest and joint protection, heat application with some use of cold, weight reduction, and exercise. Dietary supplements are not clearly supported by evidence and should not normally be substituted for pharmacologic interventions.
A patient who has experienced a rapid progression of osteoarthritis has lost a significant amount of function in his hands. This pathophysiological process has been accompanied by obvious physical changes, to which the patient has stated, "I try to keep these gnarled old hands out of sight so no one has to look at them." How can the nurse best respond to this patient's statement about body image? - Help him to focus on his strength of character more than his physical appearance. - Encourage him to focus on the function that remains rather than the function that has been lost. - Encourage him to verbalize his feelings about his appearance in more detail. - Tell him that people are not normally as judgmental and superficial as he may think they are.
Correct response: Encourage him to verbalize his feelings about his appearance in more detail. Explanation: The nurse should encourage the patient and family to verbalize feelings, perceptions, and fears related to the disease. It is incorrect to deflect or downplay his concerns.
The clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient? - Fatigue - Constipation - Impaired skin integrity - Altered nutrition
Correct response: Fatigue Explanation: Fatigue would be the priority nursing diagnosis in this scenario. Fibromyalgia is a common syndrome that involves fatigue, generalized muscle aching, and stiffness. Impaired skin integrity would generally not be a diagnosis seen in these patients. Altered nutrition is a potential nursing diagnosis, but is not the priority. Constipation is not associated with fibromyalgia.
The nurse is caring for a client who has been diagnosed with a "rheumatic disease." What nursing diagnoses will most likely apply to this client's care? Select all that apply. - Fluid volume deficit - Fluid and electrolyte imbalance - Pain - Fatigue - Alteration of self-concept
Correct response: Fatigue Pain Alteration of self-concept Explanation: Clients with rheumatic diseases, which typically involve joints and muscles, experience problems with mobility, fatigue, and pain. Because of the limitations of the disease, clients often have an altered self-image and self-concept. Fluid and electrolyte imbalances are not typically associated with these types of diseases.
An 81-year-old man with dementia and advanced osteoarthritis has been placed in an extended-care facility. In light of this man's rheumatoid disorder and the need to preserve his current level of mobility, how should the nurse at the facility best position him in bed before he retires each night? - Flat, on a firm mattress with two pillows under his head - Supine on a pressure-reducing air mattress - In a semi-Fowler's position with a pillow under his knees - Flat, with his feet positioned against a footboard
Correct response: Flat, with his feet positioned against a footboard Explanation: Proper body positioning is essential to minimize stress on inflamed joints and prevent deformities that limit mobility. All joints should be supported in a position of optimal function. When in bed, the patient should lie flat on a firm mattress, with feet positioned against a footboard and with only one pillow under the head because of the risk of dorsal kyphosis. A pillow should not be placed under the knees, because this promotes flexion contracture.
A resident of an assisted-living facility was forced to call for help after she was unable to stand up from the toilet in her bathroom. The woman is embarrassed that she needed this assistance, and the nurse who oversees the facility knows that this situation was primarily due to the resident's rheumatoid arthritis. How should the nurse best respond to this resident's decreased mobility? - Encourage the woman to keep a portable phone in her bathroom. - Have grab bar installed in the woman's bathroom. - Create a new exercise regimen for the woman to follow. - Provide a cane for the woman to keep in her bathroom.
Correct response: Have grab bar installed in the woman's bathroom. Explanation: Adaptive equipment should be provided whenever necessary, and a grab bar is safer and more effective than a cane. Physical activity is beneficial but will not necessarily prevent this specific problem in the future.
A 66-year-old man who originally sought care because of increasing pain in his great toe has subsequently been diagnosed with gout. In addition to pharmacological interventions, what dietary regimen should the nurse recommend to this patient? - High fluid intake and low protein intake - High simple carbohydrate intake and avoidance of dairy products - High calcium intake and low fat intake - Low complex carbohydrate intake and high potassium intake
Correct response: High fluid intake and low protein intake Explanation: It is important that patients with gout drink plenty of fluids, at least 2,000 mL daily, to lessen renal involvement and the development of urinary stones. Although special dietary restrictions are controversial, some health care providers recommend patients to restrict consumption of foods high in purines, especially organ meats and shellfish; others believe that limiting protein foods or avoiding trigger foods is sufficient. It is unnecessary to avoid dairy products, to increase potassium or calcium intake, or to significantly adjust carbohydrate intake.
A 62-year-old male patient has been prescribed allopurinol (Zyloprim) for the treatment of gout. When providing health education to this patient about his new medication, the nurse should know that this drug achieves a therapeutic effect by: - Interrupting the breakdown of purines - Buffering the presence of uric acid in joints - Inhibiting the inflammatory process - Increasing renal excretion of uric acid
Correct response: Interrupting the breakdown of purines Explanation: Allopurinol is a xanthine oxidase inhibitor that interrupts the breakdown of purines before uric acid is formed. It does not directly influence renal function or the inflammatory process.
5) ** A client with rheumatoid arthritis reports joint pain. What intervention is a priority to assist the client? Opioid therapy Ice packs Surgery Nonsteroidal anti-inflammatory drugs
Correct response: Nonsteroidal anti-inflammatory drugs Explanation: Nonsteroidal anti-inflammatory drugs are the mainstay of treatment for rheumatoid arthritis pain. They help to decrease inflammation in the joints. Heat, rather than ice packs, is used to relieve pain. Paraffin baths may also help. Surgery is reserved for joint replacement when the joint is no longer functional; it is not an intervention specific to relieving pain
A patient in the early stage of rheumatoid arthritis (RA) has recently been diagnosed. What medication classification would the nurse expect to be ordered for this patient? Antimalarial agents Nonsteroidal anti-inflammatory drugs (NSAIDs) Xanthine oxidase inhibitors Uricosuric agents
Correct response: Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: Medical management of RA begins with therapeutic doses of salicylates or NSAIDs. Antimalarial agents are used in the treatment of systemic lupus erythematosus. Xanthine oxidase inhibitors and uricosuric agents are used in the treatment of gout.
The assessment of a patient with SLE would include evaluation for common disorders (>50% occurrences). Select all that apply. - Pleuritis - Atherosclerosis - Pericarditis - Retinitis - Diverticulitis - Glomerulonephritis
Correct response: Pericarditis Glomerulonephritis Atherosclerosis Pleuritis Explanation: Pericarditis and pleuritis are the most common cardiopulmonary disorders. Women who have SLE are also at risk for early atherosclerosis. About 50% of patients with SLE have renal disease, such as glomerulonephritis.
The nurse is performing discharge teaching for a client with rheumatoid arthritis. What teachings are priorities for the client? Select all that apply. - Dressing changes - Narcotic safety - Assistive devices - Safe exercise - Medication dosages and side effects
Correct response: Safe exercise Medication dosages and side effects Assistive devices Explanation: The client with rheumatoid arthritis who is being discharged to home needs information on how to exercise safely to maintain joint mobility. Medication doses and side effects are always an essential part of discharge teaching. Assistive devices, such as splints, walkers, and canes, may assist the client to perform safe self-care. Narcotics are not commonly used, and there would be no reason for dressings.
The nurse is providing medication teaching to a client with rheumatoid disease. What common actions are seen with diclofenac and aspirin? Select all that apply. - anti-inflammatory - antiplatelet - analgesic - antispasmodic - antipyretic
Correct response: anti-inflammatory analgesic antipyretic antiplatelet Explanation: Rheumatoid medications like aspirin and diclofenac actions are anti-inflammatory, analgesic, antiplatelet, and antipyretic. Diclofenac has antispasmodic actions but aspirin does not.
A 40-year-old woman was diagnosed with Raynaud's phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The patient also states that many of her skin surfaces are stiff, like the skin is being stretched from all directions. The nurse should recognize the need for medical referral for the assessment of what health problem? A) Giant cell arteritis (GCA) B) Fibromyalgia (FM) C) Rheumatoid arthritis (RA) D) Scleroderma
D) Scleroderma Scleroderma starts insidiously with Raynaud's phenomenon and swelling in the hands. Later, the skin and the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. This progression of symptoms is inconsistent with GCA, FM, or RA.
A patient's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary care provider has added prednisone to the patient's drug regimen. What principle will guide this aspect of the patient's treatment? A) The patient will need daily blood testing for the duration of treatment. B) The patient must stop all other drugs 72 hours before starting prednisone. C) The drug should be used at the highest dose the patient can tolerate. D) The drug should be used for as short a time as possible.
D) The drug should be used for as short a time as possible. Corticosteroids are used for shortest duration and at lowest dose possible to minimize adverse effects. Daily blood work is not necessary and the patient does not need to stop other drugs prior to using corticosteroids.
Antinuclear antibody (ANA) - Measures - Usually the .. - Levels
Measures antibodies that react with a variety of nuclear antigens Usually the first step, if antibodies are present, further testing determines specific circulating antibodies to extractable nuclear antigens (anti-dsDNA, anti-RNP, anti Ro-SSA). Screen: negative by ELISA and IFA methods If positive by IFA, specimen is titered. Titer: less than 1:160 Low titers are present in elderly and some healthy adults **** ANA titer of 1:640 is defined as a "high titer" because of a 0.5% prevalence of positives in normal individuals. ***high titer group (≥1:640) and low titer group (<1:640).*** Likewise, what does an ANA titer of 1 320 mean? If the ANA titre is high (e.g. 1:640, 1:1280 or 1:2560), this indicates more severe disease. If the ANA titre is low (e.g. 1:40, 1:80 or even 1:160), there is often no autoimmune disease.*** Positive test is associated with systemic rheumatic disease, such as mixed connective tissue disease, SLE, RA, scleroderma, CREST syndrome, can be seen in elderly The higher the titer, the greater the inflammation Some negative ANA findings have been found to have positive anti-Ro (SSA)
Complement C3 constitutes.. Levels—C3, C4 Decrease in these levels may been seen in
* Complement Levels—C3, C4 - C3 constitutes 70% of the total protein in the complement system (antigen-antibody complexes) - Levels - ** C3: 75-175 mg/dL (or 0.75-1.75 g/L) ** C4: 14-40 mg/dL (or 140-400 mg/L) - Decrease may be seen in active SLE, immune complex disease (i.e., RA) Decrease indicates autoimmune activity
A nurse is planning the care of a patient who has fibromyalgia and is aware of the damaging effect that the disease has had on the patient's quantity and quality of sleep. When discussing strategies to manage this problem with the patient, the nurse should recommend: - Daily use of over-the-counter sleep aids - Setting consistent times for going to bed and for getting up in the morning - Maintaining the room at as high a temperature as the patient can tolerate - Performing vigorous exercise in the late evening
Answer - Setting consistent times for going to bed and for getting up in the morning
A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following? A) Hydromorphone (Dilaudid) B) Methotrexate (Rheumatrex) C) Allopurinol (Zyloprim) D) Prednisone
B) Methotrexate (Rheumatrex) In the past, a step-wise approach starting with NSAIDs was standard of care. However, evidence clearly documenting the benefits of early DMARD (methotrexate [Rheumatrex], antimalarials, leflunomide [Arava], or sulfasalazine [Azulfidine]) treatment has changed national guidelines for management. Now it is recommended that treatment with the non-biologic DMARDs begin within 3 months of disease onset. Allopurinol is used to treat gout. Opioids are not indicated in early RA. Prednisone is used in unremitting RA.
A patient has been has been admitted with an exacerbation of rheumatoid arthritis (RA). The nurse documents joint pain and swelling after performing the initial nursing assessment. In addition to these findings, what is a classic sign of RA? A) Cool extremities B) Butterfly rash on face C) Joint stiffness D) Absence of wrinkles
C) Joint stiffness Joint stiffness and swelling esp. in the morning. Extremities would be warm. Butterfly rash is SLE Absence of wrinkles is scleroderma
A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A) Cool joints with decreased range of motion B) Signs of systemic infection C) Joint stiffness, especially in the morning D) Visible atrophy of the knee and shoulder joints
C) Joint stiffness, especially in the morning In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the disease. Joints are often warm rather than cool.
A clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient? A) Impaired Urinary Elimination Related to Neuropathy B) Altered Nutrition Related to Impaired Absorption C) Disturbed Sleep Pattern Related to CNS Stimulation D) Fatigue Related to Pain
D) Fatigue Related to Pain Fibromyalgia is characterized by fatigue, generalized muscle aching, and stiffness. Impaired urinary elimination is not a common manifestation of the disease. Altered nutrition and disturbed sleep pattern are potential nursing diagnoses, but are not the priority.
Uric Acid - Measures - Men Levels - Women Levels - Biologic Crystallization Point - Increase is seen w/ - - When there is an
Measures level of uric acid in serum Men, 3.4-7 mg/dL (202-416 μmol/L) Women, 2.4-6 mg/dL (143-357 μmol/L) Biologic Crystallization Point, at least 6.8 mg/dL (408 μmol/L) Increase is seen with gout, where there is an overproduction of uric acids that occurs when there is excessive cell breakdown and catabolism of nucleonic acids
A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patient's care, what goal should the nurse include? A) The patient will express satisfaction with her ability to perform ADLs. B) The patient will recover from OA within 6 months. C) The patient will adhere to the prescribed plan of care. D) The patient will deny signs or symptoms of OA.
A) The patient will express satisfaction with her ability to perform ADLs. Pain management and optimal functional ability are major goals of nursing interventions for OA. Cure is not a possibility and it is unrealistic to expect a complete absence of signs and symptoms. Adherence to the plan of care is highly beneficial, but this is not the priority goal of care.
A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the patient is experiencing adverse effects of this drug? A) I have this ringing in my ears that just won't go away. B) I feel so foggy in the mornings and it takes me so long to wake up. C) When I eat a meal that's high in fat, I get really nauseous. D) I seem to have lost my appetite, which is unusual for me.
A) I have this ringing in my ears that just won't go away. Tinnitus is associated with salicylate therapy. Salicylates do not normally cause drowsiness, intolerance of high-fat meals, or anorexia.
The nursing educator is talking with a group of recent nursing graduates about common diagnoses on the unit. What diffuse connective tissue disease would the instructor tell the group is caused by an autoimmune reaction that results in phagocytosis, producing enzymes within the joint that break down collagen and cause edema? - Systemic lupus erythematosus (SLE) - Rheumatoid arthritis (RA) - Osteoporosis - Polymyositis
Correct response: Rheumatoid arthritis (RA) Explanation: In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately forms pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not result in phagocytosis.
A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient expresses angerand irritation when her call bell isn't answered immediately. What would be the most appropriate response? A) "You seem like you're feeling angry. Is that something that we could talk about?" B) "Try to remember that stress can make your symptoms worse." C) "Would you like to talk about the problem with the nursing supervisor?" D) "I can see you're angry. I'll come back when you've calmed down."
A) "You seem like you're feeling angry. Is that something that we could talk about?" The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care, as well as sensitivity to the psychological reactions of the patient. Offering to listen to the patient express anger can help the nurse and the patient understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the patient to calm down doesn't acknowledge her feelings. Ignoring the patient's feelings suggests that the nurse has no interest in what the patient has said. Offering to get the nursing supervisor also does not acknowledge the patient's feelings.
A nurse is planning the care of a patient who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. What nursing diagnosis is most likely to apply to this woman's care needs? A) Ineffective Role Performance Related to Pain B) Risk for Impaired Skin Integrity Related to Myalgia C) Risk for Infection Related to Tissue Alterations D) Unilateral Neglect Related to Neuropathic Pain
A) Ineffective Role Performance Related to Pain Typically, patients with fibromyalgia have endured their symptoms for a long period of time. The neuropathic pain accompanying FM can often impair a patient's ability to perform normal roles and functions. Skin integrity is unaffected and the disease has no associated infection risk. Activity limitations may result in neglect, but not of a unilateral nature.
A patient's decreased mobility is ultimately the result of an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This patient has been diagnosed with what health problem? A) Rheumatoid arthritis (RA) B) Systemic lupus erythematosus C) Osteoporosis D) Polymyositis
A) Rheumatoid arthritis (RA) In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately form pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not involve pannus formation.
A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor? A) The patient has a 30 pack-year smoking history. B) The patient's body mass index is 34 (obese). C) The patient has primary hypertension. D) The patient is 58 years old.
B) The patient's body mass index is 34 (obese). Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not include smoking or hypertension. Incidence increases with age, but a patient who is 58 would not yet face a significantly heightened risk.
A clinic nurse is caring for a patient diagnosed with rheumatoid arthritis (RA). The patient tells the nurse that she has not been taking her medication because she usually cannot remove the childproof medication lids. How can the nurse best facilitate the patient's adherence to her medication regimen? A) Encourage the patient to store the bottles with their tops removed. B) Have a trusted family member take over the management of the patient's medication regimen. C) Encourage her to have her pharmacy replace the tops with alternatives that are easier to open. D) Have the patient approach her primary care provider to explore medication alternatives.
C) Encourage her to have her pharmacy replace the tops with alternatives that are easier to open. The patient's pharmacy will likely be able to facilitate a practical solution that preserves the patient's independence while still fostering adherence to treatment. There should be no need to change medications, and storing open medication containers is unsafe. Delegating medications to a family member is likely unnecessary at this point and promotes dependence.
A 70-year-old woman has begun treatment for rheumatoid arthritis with nonsteroidal anti-inflammatory drugs (NSAIDs). The nurse should consequently monitor the patient for signs and symptoms of what adverse effect? - Gastrointestinal (GI) bleeding - Fatigue and confusion - Cardiovascular (CV) complications - Nausea and vomiting
Correct response: Gastrointestinal (GI) bleeding Explanation: NSAIDs carry a risk of GI bleeding. They do not commonly cause fatigue, CV complications, confusion, or nausea and vomiting.
A nurse is caring for a patient newly diagnosed with osteoarthritis (OA). The patient asks the nurse what causes OA. What would the nurse tell the patient is a well-recognized risk factor for osteoarthritis? Smoking Obesity Weight loss Male sex
Correct response: Obesity Explanation: Risk factors for OA include increased age, obesity, and previous joint damage. Risk factors of OA do not include smoking, weight loss, or male sex.
3) ** Which disorder is characterized by a butterfly-shaped rash across the bridge of the nose and cheeks? Rheumatoid arthritis (RA) Scleroderma Systemic lupus erythematosus (SLE) Polymyositis
Correct response: Systemic lupus erythematosus (SLE) Explanation: The most familiar manifestation of SLE is an acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and the cheeks. This type of rash does not characterize RA, scleroderma, or polymyositis.
A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this patient, what management technique should the nurse emphasize? A) Take OTC calcium supplements consistently. B) Restrict consumption of foods high in purines. C) Ensure fluid intake of at least 4 liters per day. D) Restrict weight-bearing on right foot.
B) Restrict consumption of foods high in purines. Although severe dietary restriction is not necessary, the nurse should encourage the patient to restrict consumption of foods high in purines, especially organ meats. Calcium supplementation is not necessary and activity should be maintained as tolerated. Increased fluid intake is beneficial, but it is not necessary for the patient to consume more than 4 liters daily.
A patient with SLE asks the nurse why she has to come to the office so often for check-ups. What would be the nurse's best response? A) Taking care of you in the best way involves seeing you face to face. B) Taking care of you in the best way involves making sure you are taking your medication the way it is ordered. C) Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working. D) Taking care of you in the best way involves drawing blood work every month.
C) Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working. The goals of treatment include preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease-related disabilities, and preventing complications from therapy. Management of SLE involves regular monitoring to assess disease activity and therapeutic effectiveness. Stating the benefit of face-to-face interaction does not answer the patient's question. Blood work is not necessarily drawn monthly and assessing medication adherence is not the sole purpose of visits.
4) ** A patient is hospitalized with a severe case of gout. The patient has gross swelling of the large toe and rates pain a 10 out of 10. With a diagnosis of gout, what should the laboratory results reveal? Glucosuria Hyperuricemia Hyperproteinuria Ketonuria
Correct response: Hyperuricemia Explanation: Gout is caused by hyperuricemia (increased serum uric acid)
A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed cyclophosphamide (Cytoxan). The nurse's subsequent assessments should address what potential adverse effect? A) Infection B) Acute confusion C) Sedation D) Malignant hyperthermia
Answer - A) Infection When administering immunosuppressives such as Cytoxan, the nurse should be alert to manifestations of bone marrow suppression and infection. Confusion and sedation are atypical adverse effects. Malignant hyperthermia is a surgical complication and not a possible adverse effect. Assess for bone marrow suppression, GI ulcerations, skin rashes, alopecia, bladder toxicity, increased infections Monitor CBC, liver enzymes, creatinine every 2-4 weeks Advise patient of contraceptive measures because of teratogenicity
A nurse in a long-term care facility has a longstanding relationship with a female resident whose osteoarthritis has become more severe in recent months. To facilitate the resident's continued engagement in activities and to promote her mobility, the nurse has begun implementing motivational interviewing (MI). The resident has stopped attending the quilting circle, stating, "I still enjoy quilting, but my knuckles are so painful lately." What response by the nurse best exemplifies MI? - - "I would hate to see you miss out on something you enjoy because of a health problem that can be treated." - "You say you'd like to keep quilting but it's painful. What ideas do you have for reducing your pain?" - "Tell me about some of the things that you most enjoy about quilting." - "I'd encourage you to push through your pain in this situation because it will ultimately benefit you."
Correct response: "You say you'd like to keep quilting but it's painful. What ideas do you have for reducing your pain?" Explanation: The nurses' task in utilizing MI is to elicit "change talk" rather than resistance from their patients. Resistance is best handled by restating, using a "but" statement. The nurse refrains from persuading and confronting, but guides the patient toward an acceptable resolution that triggers change. The other statements do not demonstrate this communication model.
A client is admitted with an acute attack of gout. What interventions are essential for this client? Select all that apply. - Probenecid - Dietary consult - Serum uric acid concentration - Pain medication - Corticosteroid therapy
Correct response: - Dietary consult - Probenecid - Corticosteroid therapy - Pain medication - Serum uric acid concentration Explanation: Steroids may be used in clients who have not responded to other therapies. They have been shown to decrease inflammation and pain in attacks of gout. Probenecid will assist in the excretion of uric acid, the causative agent. Serum uric acid concentrations will guide therapy and treatment. A dietary consult can wait until the client the acute, painful period is over but will be a necessary nursing intervention for a client experiencing gout.
A series of laboratory tests are done to diagnose a rheumatic disorder. Which of the following are abnormal values diagnostic of this disorder? Select all that apply. - Erythrocyte sedimentation rate (ESR) of 40 mm/hr - C3 complement level of 120 mg/dL - Antinuclear antibody (ANA) titer <1:160 - Anti-ds DNA of 200 IU - Uric acid level of 4 mg/dL - Positive autoantibodies result >26 U/mL
Correct response: - Erythrocyte sedimentation rate (ESR) of 40 mm/hr - Anti-ds DNA of 200 IU - Positive autoantibodies result >26 U/mL Explanation: Refer to Table 39-1 in the text for the normal values and implications for abnormal results for rheumatic diseases. * Erythrocyte Sedimentation Rate (ESR) - Measures the rate at which RBCs settle out of unclotted blood in 1hr. Men - 0-15mm/hr over 50 yrs old - 0-20mm/hr. Women - 0-20mm/hr, over 50 yrs - 0-30mm/hr An increase indicates rising inflammation; the higher the ESR, the greater the inflammatory activity *Anti-double-stranded DNA (Anti-dsDNA) - Specific autoantibody to extractable nuclear antigens; differentiates native (i.e., double-stranded) DNA antibodies from other nonnative antibodies; - 95% specific for SLE, making it a valuable disease marker -Negative: less than 25 IU by ELISA - Positive: 31-200 IU; strongly positive: over 200 IU - Anti-dsDNA concentrations may decrease with successful therapy, may increase with exacerbation of SLE *Autoantibodies - Negative: less than 20 U/mL by ELISA Positive: greater than 26
Which intervention should the nurse implement to manage pain for the client with rheumatoid arthritis? Select all that apply. - Provide diversional activities. - Assist the client to develop a sleep routine. - Support joints with splints and pillows. - Provide opportunities for the client to verbalize feelings. - Provide assistive devices for self-feeding.
Correct response: - Support joints with splints and pillows. - Provide diversional activities. - Provide opportunities for the client to verbalize feelings. Explanation: To manage pain, the nurse maintains normal alignment of extremities as much as possible by supporting the joints with splints and pillows. Diversional activities distract the client's focus from the pain. Providing opportunities for the client to verbalize feelings facilitates coping with pain. Assistive devices for self-feeding help the client meet nutritional needs independently. Assisting the client to develop a sleep routine promotes rest and minimizes fatigue.
The nurse is working with a client with systemic lupus erythematosus (SLE). What are the immune abnormalities characterized by SLE? Select all that apply. - damage - inflammation - susceptibility - abnormal innate and adaptive immune responses - autoantibodies immune complexes
Correct response: - susceptibility - abnormal innate and adaptive immune responses - autoantibodies immune complexes - inflammation - damage Explanation: The immune abnormalities that characterize SLE occur in five phases: susceptibility, abnormal innate and adaptive immune responses, autoantibodies immune complexes, inflammation, and damage.
A nurse at a small, rural nursing station that lacks the services of a physical therapist is responsible for planning the care of a local resident who has rheumatoid arthritis. When planning a regimen of physical activity for this patient, what principle should underlie the nurse's choice of interventions? - ROM exercises should be passive (performed by the nurse) whenever possible. - Joints should be splinted whenever physical activity is performed. - Active range-of-motion (ROM) exercises can reduce joint stiffness. - Limiting physical activity slows the progression of rheumatoid disorders.
Correct response: Active range-of-motion (ROM) exercises can reduce joint stiffness. Explanation: Exercise is a fundamental part in the management of rheumatic disorders. Active and active/self-assisted ROM exercises are encouraged because they prevent joint stiffness and increase mobility. Passive ROM is not currently recommended, and splinting should be used with caution due to the possible loss of ROM.
21) ** 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.
