Exam 1: Rheumatoid Arthritis Questions

A client with rheumatoid arthritis has been taking a steroid medication for the past year. For which complication of prolonged use of this medication should the nurse assess the client? 1. decreased WBCs 2. increased c-reactive protein 3. increased sedimentation rate 4. decreased serum glucose levels

1 rationale: Prolonged use of steroids may cause leukopenia as a result of bone marrow depression. C-reactive protein and sedimentation rate are elevated in acute inflammatory diseases; steroids help decrease it. Serum glucose levels increase with steroid use.

What is the nurse's primary consideration when caring for a client with rheumatoid arthritis? 1. surgery 2. comfort 3. education 4. motivation

2 Rationale: Because pain is an all-encompassing and often demoralizing experience, the client should be kept as pain-free as possible. Surgery is used to correct deformities and facilitate movement, which is not the priority. Concentration and motivation are difficult when a client is in severe pain.

A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client asks the nurse, "What kind of drug is acetylsalicylic acid?" The nurse recalls that this drug has which property? 1. Sedative 2. Hypnotic 3. Analgesic 4. Antibiotic

3 rationale: Acetylsalicylic acid (aspirin) acts as an analgesic by inhibiting production of inflammatory mediators. Acetylsalicylic acid does not act as a sedative to calm individuals. Acetylsalicylic acid does not act as a hypnotic to induce sleep. Acetylsalicylic acid does not destroy or control microorganisms.

A pregnant client with a history of rheumatic heart disease expresses concern about the impending birth. What should the nurse tell her to expect? 1. induced labor 2. cesarean birth 3. regional analgesia 4. inhalation anesthesia

3 rationale: Regional analgesia, such as an epidural, will relieve the stress of pain, and it does not compromise cardiovascular function. Induced labor is often more stressful and painful than spontaneous labor. Major abdominal surgery is performed in clients with cardiac problems only when absolutely necessary. Inhalation anesthesia can compromise cardiovascular function.

Which medication should the nurse anticipate the healthcare provider will prescribe to relieve the pain experienced by a client with rheumatoid arthritis? 1. aspirin 2. hydromorphone 3. meperidine 4. alprazolam

1 Rationale: Because of its antiinflammatory effect, acetylsalicylic acid is useful in treating arthritis symptoms. Opioids such as hydromorphone and meperidine should be avoided because they promote drug dependency and do not affect the inflammatory process. Alprazolam is an antianxiety, not an antiinflammatory, agent.

The parents of a 12-year-old child with juvenile idiopathic arthritis ask a nurse why their child is not receiving steroid therapy when it is so effective for adults with rheumatoid arthritis. Which reason that steroids are avoided at this time takes priority in the nurse's explanation? 1. Steroids could affect growth. 2. Body image is adversely affected. 3. Steroids could lead to flat emotions. 4. Steroids have adverse effects on sexuality.

1 rationale: Preadolescence is a critical period of growth, and steroids could lead to growth retardation. Impaired body image is a result of many variables, not just medications. The most important and most physiologically detrimental reason that steroids are avoided are these drugs' effects on growth. Although mood changes have been documented, this is not the reason that steroids are avoided during preadolescence. The effect of steroids on sexuality is unclear.

What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever? 1. negative c-reactive protein 2. increased reticulocyte count 3. positive antistreptolysin titer 4. decreased sedimentation rate

3 rationale: A positive antistreptolysin titer is present with rheumatic fever because of the previous infection with streptococci. An increased reticulocyte count is usually related to a decrease in mature red blood cells caused by hemorrhage or blood dyscrasias; it is unrelated to an infectious or inflammatory process. A positive, not a negative, C-reactive protein will be present; this is indicative of an inflammatory process. The erythrocyte sedimentation rate will be increased, not decreased, indicating the presence of an inflammatory process.

The nurse is providing discharge teaching to a 30-year-old client who was hospitalized for exacerbation of rheumatoid arthritis. Which statement by the client indicates correct understanding of the treatment plan? 1. "i will plan to rest in bed for the next 2 weeks" 2. "i will only take my medications when i am having joint pain" 3. "when i exercise i will reduce the number of repetitions when i have pain" 4. "when i get out of bed, i will push off with my fingers rather than the palms of my hands"

3 rationale: The amount of exercise and number of repetitions should be reduced to prevent further joint damage if the client is experiencing increased pain. Activity should be balanced with rest. Medications should not be discontinued without consulting the primary healthcare provider. Pushing off with fingers may cause further damage to the phalangeal joints.

The nurse is assessing a client with severe nodule-forming rheumatoid arthritis for possible Felty syndrome. Which assessment findings are consistent with Felty syndrome? Select all that apply. 1. itchy eyes 2. dry mouth 3. leukopenia 4. splenomegaly 5. photosensitivity

3, 4 Rationale: Felty syndrome occurs most commonly in clients with severe nodule-forming rheumatoid arthritis; it is characterized by splenomegaly and leukopenia. Itchy eyes, dry mouth, and photosensitivity are all signs of Sjögren syndrome.

Which type of hypersensitivity reaction is associated with rheumatoid arthritis? 1. delayed 2. cytotoxic 3. IgE-mediated 4. Immune-complex

4 Rationale: Rheumatoid arthritis is an autoimmune disorder associated with an immune-complex type of hypersensitivity reaction. Contact dermatitis caused by poison ivy is associated with a delayed type of hypersensitivity reaction. Goodpasture's syndrome is associated with a cytotoxic type of hypersensitivity reaction. Asthma is associated with an IgE-mediated type of hypersensitivity reaction.

A nurse plans care to prevent deformities in a client with rheumatoid arthritis. Which intervention should be alternated with periods of rest? 1. active exercises 2. passive massage 3. bracing of joints 4. isometric exercises

1 rationale: Active exercises, alternated with periods of rest, offer the best chance at preventing the joint deformities associated with rheumatoid arthritis, because they can move each involved joint through its full range of motion. Massage affects the muscles, not the joints, and will do little to prevent deformities. Immobilization of joints by bracing will promote the formation of contractures and deformities. Isometric exercises will promote muscle, not joint, function.

A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? 1. "Your primary healthcare provider must have forgotten to prescribe it." 2. "Your condition is not severe enough to have physical therapy approved." 3. "Your joints are still inflamed, and physical therapy can be harmful." 4. "Physical therapy is not helpful for persons who suffer from RA."

3 rationale: Rest is required during active inflammation of the joints to prevent injury; once active inflammation has receded, an activity and exercise regimen can begin. Physical therapy is not prescribed during a period of exacerbation because it can traumatize already inflamed joints. The extent of the arthritis is not the determinant; whether the process is in exacerbation or remission is the deciding factor. Physical therapy is helpful, but it is not performed during an acute exacerbation of the arthritis.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client? 1. Control of pain 2. Immobilization of joints 3. Motivation and teaching 4. Bladder training and control

1 rationale: After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client's basic needs. Joints must be exercised, not immobilized, to prevent stiffness, contractures, and muscle atrophy. Motivation and learning will not occur unless basic needs, such as freedom from pain, are met. Although bladder training should be included in care, it is not the priority when the client is in pain.

A client newly diagnosed with rheumatoid arthritis is admitted to the hospital with bilateral painful knee and wrist joints. The nurse identifies impaired physical mobility related to painful, swollen joints. What should the nurse teach the client to do during the acute phase of the disease? 1. avoid exercises to the involved joints 2. engage in passive exercises to the involved joints 3. increase isometric exercises to the involved joints slowly 4. participate in progressive, resistive exercises to the involved joints

1 rationale: During the acute phase, immobilization of the joints reduces pain and inflammation. Passive exercises are contraindicated during the acute inflammatory phase; joints need to be immobilized. Isometric exercises involve muscles, not joints. Progressive, resistive exercises are contraindicated during the acute inflammatory phase because joints need to be immobilized to reduce pain and inflammation.

On her first visit to the prenatal clinic, a client with rheumatic heart disease asks the nurse whether she has any special nutritional needs. What supplements in addition to the regular pregnancy diet and prenatal vitamin and minerals will she need? Select all that apply. 1. iron 2. calcium 3. folic acid 4. vitamin C 5. vitamin B 12

1, 3 rationale: Because pregnant women with heart disease are more likely to have anemia, there may be an additional need for iron and for folic acid. If the pregnant client with heart disease is eating the recommended pregnancy diet and taking prenatal vitamin and mineral supplements, there is no additional need for calcium, vitamin C, or vitamin B 12.

Which nursing actions should be effective for a client with rheumatoid arthritis who is receiving anakinra therapy? Select all that apply. 1. monitoring the injection site 2. monitoring the blood pressure 3. teaching the patient to report chest pain 4. monitoring the WBC count 5. teaching the client to report difficulty in breathing

1, 4, 5 rationale: For the clients who are receiving anakinra therapy, the nurse should monitor the injection site as site reactions may occur. The nurse should also monitor the WBC count as the drug can cause a severe decrease in WBCs, which makes the client more susceptible to infection. The nurse should teach the client to report difficulty breathing as anakinra can cause serious respiratory infections and various types of cancer. The nurse should monitor the blood pressure in clients who are receiving infliximab therapy. The nurse should teach clients who are receiving infliximab therapy to report chest pain.

A nurse is caring for a client with severe rheumatoid arthritis. What is most important in the nurse's approach to help this client achieve self-reliance and independence? 1. A series of limited objectives 2. A positive attitude toward the eventual outcome 3. The understanding that little can be accomplished 4. The recognition that a nursing home type of facility is needed

2 rationale: A nurse's positive attitude can encourage and motivate a client. As many objectives as needed should be used. The attitude that little can be accomplished may discourage the client's attempts to attain the highest goals possible. The recognition that a nursing home type of facility is needed may discourage the client's attempts to attain the highest goals possible.

On reviewing the x-ray report of a client with rheumatoid arthritis, the nurse learns that three small joints are involved. According to the diagnostic criteria for rheumatoid arthritis, which score will the nurse assign the client for joint involvement? 1. 1 2. 2 3. 3 4. 5

2 rationale: According to the diagnostic criteria for rheumatoid arthritis, involvement of one to three small joints (with or without large-joint involvement) is given a score of 2. Involvement of two to ten large joints is given a score of 1. Involvement of four to ten small joints (with or without large-joint involvement) is given a score of 3. Involvement of more than ten joints (and at least one small joint) is given a score of 5.

A client with rheumatoid arthritis is receiving etanercept therapy. Which instruction should the nurse share with the client? 1. report chest pain 2. report site reaction 3. report blurry vision 4. report difficulty in breathing during infusion

2 rationale: The nurse should teach a client who is receiving etanercept therapy to report signs of site reaction, as they are very painful. The nurse should teach a client who is receiving infliximab therapy to report chest pain. Blurry vision does not occur with etanercept. The nurse should teach a client who is receiving infliximab therapy to report difficulty in breathing during intravenous infusion; etanercept is given subcutaneously.

Which drugs are used for the treatment of clients with rheumatoid arthritis that inhibit tumor necrosis factor-A? Select all that apply. 1. anakinra 2. infliximab 3. abatacept 4. etanercept 5. golimumab

2, 4, 5 rationale: Biological response modifiers (BRMs) are the substances that modify immune responses by either enhancing an immune response or suppressing it. Infliximab, etanercept, and golimumab are BRMs used in the treatment of rheumatoid arthritis that inhibit tumor necrosis factor (TNF)-A. Anakinra is aninterleukin-1 receptor antagonist used in the treatment of rheumatoid arthritis. Abatacept is a selective T-lymphocyteco-stimulator modulator (T-cell inhibitor) used in the treatment of rheumatoid arthritis.

A client who has been taking ibuprofen for rheumatoid arthritis asks the nurse if acetaminophen can be substituted instead. What is the appropriate nursing response? 1. "acetaminophen is the preferred treatment for rheumatoid arthritis" 2. "acetaminophen irritates the stomach more than ibuprofen does" 3. "ibuprofen has antiinflammatory properties and acetaminophen does not" 4. "yes, both are antipyretics and have the same effect"

3 Rationale: Ibuprofen has an antiinflammatory action that relieves the inflammation and pain associated with arthritis. Acetaminophen is not a nonsteroidal antiinflammatory drug (NSAID). NSAIDs are preferred for the treatment of rheumatoid arthritis. Acetaminophen does not cause gastritis; this is an effect of aspirin. Ibuprofen is not an antipyretic.

After a painful exacerbation of rheumatoid arthritis, a client is scheduled to begin a walking and exercise program. Which is an expected outcome for this client? 1. Only when pain free, begin exercising as part of a formal activity program. 2. Avoid exercising when there is a moderate amount of discomfort. 3. Exercise and be active unless the discomfort becomes too great. 4. Walk and exercise even when the pain is severe.

3 rationale: Some pain is to be expected, but the activity should not be continued when the pain becomes severe, because it can further traumatize the inflamed synovial membranes. It is unrealistic to expect the client to be pain free, so exercise would never begin. Some discomfort is expected; inactivity promotes the development of muscle atrophy and joint contracture. Activity should be curtailed when pain is severe.

Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the drug is being used primarily for which of its properties? 1. Analgesic 2. Antipyretic 3. Antiinflammatory 4. Antiplatelet

3 rationale: The antiinflammatory action of aspirin reduces joint inflammation. Aspirin reduces fever, but this is not the rationale for prescribing it for clients with rheumatoid arthritis. Aspirin does not preserve bone integrity. Flexion contractures are prevented by exercise, not aspirin.

The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the client to experience the most pain and limited movement of the joints? 1. After assistive exercise 2. When the room is cool 3. During the evening hours 4. In the morning on awakening

4 rationale: Inactivity over an extended time increases stiffness and pain in joints. The client typically has morning stiffness, or gel phenomenon. Assistive exercises help maintain joint mobility. Whether the room is cool is not a factor; cold applications may decrease joint discomfort. The pain is not as severe in the evening as in the morning.

After assessing a client with rheumatoid arthritis, the nurse suspects Sjögren's syndrome. Which manifestations are consistent with Sjögren's syndrome? Select all that apply. 1. iritis 2. scleritis 3. xerostomia 4. baker's cyst 5. keratoconjunctivitis sicca

3, 5 Rationale: Sjögren's syndrome, commonly associated with advanced rheumatoid arthritis, includes such symptoms as xerostomia (dry mouth) and keratoconjunctivitis sicca (dry eyes). Iritis and scleritis are eye complications and do not indicate Sjögren's syndrome. A Baker's cyst is an enlargement of a popliteal bursa (behind the knee); it is commonly found in people with rheumatoid arthritis but does not indicate Sjögren's syndrome.

Client A: serological study: uric acid results: 8.5 mg/dL Client B: serological study: C-reactive protein (CRP) results: 800 mcg/dL Client C: serological study: anti-deoxyribonucleic acid (DNA) antibody results: 90 IU/mL Client D: serological study: erythrocyte sedimentation rate (ESR) results: 65 mm/hour A nurse is reviewing the laboratory reports of four clients. Which client most likely has rheumatoid arthritis? 1. Client A 2. Client B 3. Client C 4. Client D

4 rationale: Erythrocyte sedimentation rate (ESR) is a nonspecific index of inflammation. Its normal value is less than 30 mm/hr. Client D, who has elevated levels of ESR to 65 mm/hr, may present with rheumatoid arthritis, osteomyelitis, rheumatic fever, and respiratory tract infections. Uric acid is an end-product of purine metabolism. The normal range of uric acid is 2.3 to 7.6 mg/dL (137-452 μmol/L). An elevation in the uric acid value in client A to 8.5 mg/dl may result in gout. The normal value of C-reactive protein (CRP) is 6.8-820 mcg/dL (68-8200 mcg/L). Client B, who presents with a normal level of CRP at 800 mcg/dL (8000 mcg/L), will not have inflammatory diseases, infections, and active, widespread malignancy. The normal value of anti-deoxyribonucleic acid (DNA) antibody is less than 70 IU/mL; it helps to detect serum antibodies that react with DNA. Client D, who has elevated levels of anti-DNA antibody at 90 IU/mL, may be more susceptible to systemic lupus erythematosus (SLE).

A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. What should the nurse suggest? 1. Wearing loose but warm clothing 2. Planning a short rest break periodically 3. Avoiding excessive physical stress and fatigue 4. Taking a hot tub bath or shower in the morning

4 rationale: Moist heat increases circulation and decreases muscle tension, which help relieve chronic stiffness. Although wearing loose but warm clothing is advisable for someone with arthritis, it does not relieve morning stiffness. Inactivity promotes stiffness. The practice of avoiding excessive physical stress and fatigue is related to muscle fatigue, not to stiffness of joints.

A nurse is performing an admission health history and physical assessment for a client who has severe rheumatoid arthritis. When assessing the client's hands, the nurse identifies that they are similar to the hand in the illustration. What should the nurse document in the medical record when describing this typical physiologic change associated with rheumatoid arthritis? 1. ulnar drift 2. hallux valgus 3. swan-neck deformity 4. boutonnière deformity

1 rationale: Ulnar drift occurs when the long axis of the fingers makes an angle with the long axis of the wrist so that the fingers are deviated to the ulnar side of the hand; it is caused by changes in the metacarpophalangeal joints. Hallux valgus occurs when the great toe is angulated away from the midline of the body toward the other toes. Swan-neck deformity occurs with flexion of the distal interphalangeal joint and hyperextension of the proximal interphalangeal joint. Boutonnière deformity occurs with fixed flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint.

A client with an acute exacerbation of rheumatoid arthritis is in severe pain and tells the nurse, "The only time I am pain free is when I lie perfectly still." What complication should the nurse explain can be prevented by exercising every day? 1. paresthesias of the feet 2. shortening of the muscles 3. development of osteoblasts 4. loss of muscular coordination

2 rationale: Flexion and extension prevent tightening of muscles and tendons. Abnormal sensations (paresthesias) are related to neurologic, not musculoskeletal, alterations. Weight bearing, not exercise, promotes the development of osteoblasts. Loss of muscular coordination is the result of cerebellar changes; it is not related to immobility.

A client experiences an acute episode of rheumatoid arthritis. The nurse observes that the client's finger joints are swollen. The nurse concludes that this swelling most likely is related to which factor? 1. Urate crystals in the synovial tissue 2. Inflammation in the joint's synovial lining 3. Formation of bony spurs on the joint surfaces 4. Deterioration and loss of articular cartilage joints

2 rationale: In rheumatoid arthritis, transformed autoantibodies attack synovium, producing inflammation. Urate crystals occur with gouty, not rheumatoid, arthritis. Formation of bony spurs on the joint surfaces is unrelated to rheumatoid arthritis. Deterioration and loss of articular cartilage in joints is osteoarthritis.

A client with rheumatoid arthritis asks the nurse why it is necessary to inject hydrocortisone into the knee joint. What reason should the nurse include in a response to this question? 1. Lubricate the joint 2. Reduce inflammation 3. Provide physiotherapy 4. Prevent ankylosis of the joint

2 rationale: Steroids have an antiinflammatory effect that can reduce arthritic pannus formation. Lubricating the joint does not provide lubrication. Injection of a drug into a joint is not physiotherapy. Ankylosis refers to fusion of joints. It is only indirectly influenced by steroids, which exert their major effect on the inflammatory process.

A nurse is caring for a client with rheumatoid arthritis. Based on the client's diagnosis, the nurse should review the result of which laboratory test? 1. Pancreatic lipase 2. Bence Jones protein 3. Antinuclear antibody 4. Alkaline phosphatase

3 rationale: An antinuclear antibody test may be positive in clients with autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. Pancreatic lipase is an enzyme that catalyzes the breakdown of lipids; this is a test used to diagnose pancreatic problems. Bence Jones protein is a urine test helpful in diagnosing multiple myeloma. Alkaline phosphatase is a blood test that determines phosphorus activity; it is used in diagnosing liver and biliary tract disorders and identifying periods of active bone growth or metastasis of cancer to bone.

A married couple in their 80s is living independently. They have three adult children. The husband, who is alert but forgetful, has an enlarged prostate and at times is incontinent of urine. The wife has diabetes and rheumatoid arthritis and walks with difficulty. Both need assistance with bathing, dressing, and meal preparation. What does the nurse suggest as the most suitable plan for this couple? 1. admit them together to a nursing home 2. place them together in an assisted-living facility 3. keep them in their home with a home health aide 4. encourage them to move in with one of their children

3 rationale: Care provided in the home is more efficient and cost-effective; this couple can manage with assistance from community resources. There is nothing in the history to demonstrate that skilled nursing care provided by a nursing home is necessary. Because the couple appears able to function with assistance at home, it is not necessary to move them to another setting at this time.

A client with painful swelling of a distal joint of the ring finger is found to be in the early stages of rheumatoid arthritis (RA). A test for the rheumatoid factor is negative. The client asks about the reliability of the test, stating, "I don't think the result is accurate. I have been diagnosed with RA, and I am in so much pain." How should the nurse respond? 1. "It might help if you try not to think about your discomfort." 2. "Don't let that upset you; eventually the tests will be positive." 3. "These tests will have to be repeated; they are complicated tests." 4. "Laboratory tests often are negative in the early stages of the disease."

4 rationale: The antibody called rheumatoid factor is not definitive for RA; it is commonly absent in the early stages of the disease. The response "It might help if you try not to think about your discomfort" denies the client's discomfort and does not address the stated confusion. The response "Don't let that upset you; eventually the tests will be positive" denies the client's immediate feelings and blocks further communication of feelings. The response "These tests will have to be repeated; they are complicated tests" reinforces the client's confusion over negative test results and feeling discomfort.

A nurse develops a teaching plan for a client with rheumatoid arthritis. What should the nurse include in the plan about ways to reduce joint stress? 1. "if experiencing pain after 1 to 2 hours of activity, actively take measures to address the pain" 2. "when performing day-to-day tasks, use smaller muscles more frequently than large muscles" 3. "schedule all of the heavy tasks at one time, and then schedule a long rest period" 4. "when the joints are swollen, an increase in exercise will help reduce swelling"

1 rationale: Addressing and managing joint pain protects the joints, especially if the pain lasts more than 1 or 2 hours after a particular activity. The client should use large muscles, such as pushing doors open with arms rather than fingers. Doing heavy tasks at one time will increase joint stress; heavy and light tasks should be alternated. When the inflammatory process is active, the joint should be at rest as much as possible.

A nurse is creating a plan of care for range-of-motion exercises for a client with rheumatoid arthritis who has severe pain and swelling of the joints in both hands. What should the plan include? 1. passively performing the exercises for the client 2. avoiding the exercises if the client reports discomfort 3. applying heat or cold before the exercises 4. gradually increasing the exercises to improve mobility and independence

3 rationale: Heat and cold applications reduce inflammation and discomfort. Passively performed exercises by the nurse will depend on the client's tolerance. Avoiding exercise will increase the destructive effects of immobility. Exercises are necessary to prevent contractures and permanent joint damage, but cannot be increased gradually unless the client is able to tolerate them.

Which joint surgery is used as a prophylactic measure and as a palliative treatment for clients with rheumatoid arthritis (RA)? 1. osteotomy 2. arthrodesis 3. synovectomy 4. debridement

3 rationale: Synovectomy is a type of joint surgery that involves the removal of thickened synovial membrane. It is used as a prophylactic measure and as a palliative treatment for rheumatoid arthritis (RA) because it prevents the serious destruction of joint surfaces. Osteotomy involves removing a wedge of bone to correct deformity and relieve pain. Arthrodesis is the surgical fusion of a joint. Debridement involves the surgical removal of degenerative debris from a joint.

Aspirin is prescribed for a client with rheumatoid arthritis. Which clinical indicators of aspirin toxicity should the nurse teach the client to report? Select all that apply. 1. nausea 2. joint pain 3. blood in the stool 4. ringing in the ears 5. increased urine output

3, 4 rationale: Blood in the stool indicates gastrointestinal irritation; it also may have resulted from aspirin's anticoagulant effect. Salicylates, such as aspirin, can cause ototoxicity (affects eighth cranial nerve), which may manifest as ringing in the ears (tinnitus) or muffled hearing; it should be reported. Nausea is a common side effect; it can be diminished by administering the drug with food or using an enteric-coated product. Joint pain is not a symptom of salicylate toxicity; it is related to the disease process and should be minimized by the administration of aspirin. Increased urine output (polyuria) is not an indication of salicylate toxicity.

A client with severe chronic rheumatoid arthritis reports that pain lasts for 2 to 3 hours after exercising. What should the nurse should teach the client to do? 1. Substitute isometric exercises for isotonic exercises. 2. Stop the exercises for one day and then resume the exercises. 3. Delay doing aerobic exercises until the pain subsides. 4. Decrease the total time and number of repetitions of the exercise

4 rationale: Exercise should be decreased to a level of tolerance. Isometric exercises promote muscle contraction, not joint movement. The exercise should not be stopped. The purpose of aerobic exercises is to improve cardiovascular functioning, not joint movement; there is no reason to interrupt aerobic exercises if they are tolerated.

A client with rheumatoid arthritis is scheduled to participate in an exercise program that is established at the extended care facility where the client resides. The nurse evaluates that the client understands the purpose of the program when the client makes which statement? 1. "I know the exercises are important, so I do them whenever I can." 2. "I do my exercises when I go to physical therapy in the morning and afternoon." 3. "Because I'm stiff in the morning, I do most of my exercises then, so I'm done for the day." 4. "After I eat breakfast, I do one set of exercises slowly, and then I space the rest of them throughout the day."

4 rationale: Spacing activity protects joints from overuse, misuse, and stress, limiting inflammation; it provides a balance between rest and activity. The exercise program should be planned; too much activity can precipitate an exacerbation, and too little may cause contractures. Spaced range-of-motion exercises should be incorporated into daily living activities, not just twice a day. The actions expressed in the response "Because I'm stiff in the morning, I do most of my exercises then, so I'm done for the day" will cause stress at the joints, which may precipitate an exacerbation.

A client who has severe rheumatoid arthritis becomes depressed and is admitted to the psychiatric unit. The nurse begins to work with the client in one-on-one sessions to help with coping with the depressive episode. What is the best long-term outcome for this client? 1. the client will eat at least two meals per day with other clients 2. the client will maintain self-care and attend structured activities 3. the client will make a positive verbal comment to another client daily 4. the client will decrease negative thinking about self, others, and life

4 rationale: The best long-term goal is that the client attains a positive attitude about the self, others, and life in general; this indicates that treatment has been effective and the client may be discharged. Eating at least two meals per day with other clients is a short-term goal associated with a therapeutic milieu. Maintaining self-care and attending structured activities is a short-term goal and an expected behavior on an inpatient unit. Making a positive verbal comment to another client daily is an intermediate goal that helps the client focus on others; this goal is a step toward achieving long-term goals.

A client who has intermittently been having painful, swollen knee and wrist joints during the past 3 months is diagnosed with rheumatoid arthritis. What type of diet should the nurse expect the primary healthcare provider to prescribe? 1. salt-free, low-fiber diet 2. high-calorie, low-cholesterol diet 3. high-protein diet with minimal calcium 4. regular diet with vitamins and minerals

4 rationale: There are no dietary restrictions, but iron and vitamins should be encouraged to treat any underlying nutritional deficiencies. A salt-free, low-fiber diet is not indicated. A high-calorie diet will increase the client's weight; this is contraindicated because it will increase the strain on weight-bearing joints. A balanced diet should fulfill nutritional needs; there is no need to increase protein or restrict calcium.

A nurse is reviewing the laboratory values of a school-aged child with rheumatic heart disease. Which finding does the nurse conclude is related to this condition? 1. negative C-reactive protein 2. increased reticulocyte count 3. positive antistreptolysin titer 4. low erythrocyte sedimentation rate

3 rationale: A positive antistreptolysin titer is expected with rheumatic fever because of a previous streptococcal infection. A positive, not a negative, C-reactive protein reading is expected with rheumatic heart disease. A positive C-reactive protein reading is indicative of an inflammatory process. An increased reticulocyte count is unexpected. An increased reticulocyte count is usually related to anemia, which stimulates the bone marrow to produce so many red blood cells that more immature blood cells (reticulocytes) enter the circulation. The erythrocyte sedimentation rate is increased, not decreased, with rheumatic heart disease, indicating the presence of an inflammatory process.

a nurse is administering gold salts to a client with the diagnosis of rheumatoid arthritis. for which adverse effect of this drug should the client be monitored? 1. kidney damage 2. persistent nausea 3. pulmonary emboli 4. cardiac decompensation

1 rationale: Gold salts, bound to plasma proteins, are distributed irregularly throughout the body, but the highest concentration occurs in the kidneys. When the slow excretion of gold salts cannot keep up with their intake, they can accumulate in the kidneys, causing damage. Persistent nausea, pulmonary emboli, and cardiac decompensation are not side effects associated with gold salts.

A client with rheumatoid arthritis is to begin taking ibuprofen 800 mg by mouth three times a day. The nurse provides education about the medication's side effects. The nurse concludes that the teaching was effective when the client makes which statement? 1. "i need to have my blood work checked periodically" 2. "i need to balance exercise with rest" 3. "i need to change positions slowly" 4. "i need to take the medication between meals"

1 rationale: If the client will be taking the medication long term, periodic diagnostic tests are necessary because ibuprofen is nephrotoxic, is hepatotoxic, and prolongs the bleeding time. Balancing exercise with rest is important for all clients with arthritis; it is not related to ibuprofen. Ibuprofen does not cause postural hypotension. Ibuprofen causes epigastric distress and occult bleeding; it should be taken with meals or milk to reduce these adverse reactions.

As an acute episode of rheumatoid arthritis subsides, active and passive range-of-motion exercises are taught to the client's spouse. The nurse should teach that direct pressure should not be applied to the client's joints, because this may precipitate what? 1. pain 2. swelling 3. nodule formation 4. tophaceous deposits

1 rationale: Palpation will elicit tenderness, because pressure stimulates nerve endings and causes pain. Pressure will not increase the swelling of already swollen joints. Nodules associated with rheumatoid arthritis are not caused by pressure; they occur spontaneously in about 25% of individuals with rheumatoid arthritis and are composed of collagen fibers, exudate, and cellular debris. Tophaceous deposits are present in gout, not rheumatoid arthritis; they are composed of sodium urate.

A client with rheumatoid arthritis arrives in the clinic stating, "I don't take any medications because they are too expensive." The client reports that family members are arranging for the medications to be obtained from another country. What is the nurse's best response? 1. Discuss alternative solutions with the client. 2. Encourage the client to use any method possible to obtain the medications. 3. Contact the primary healthcare provider immediately to discuss the client's plan. 4. Explain that medical regimens must be followed to continue to receive care in the clinic.

1 rationale: The nurse should discuss alternatives in terms of funding, such as Medicaid, research projects, and special aid. Standards outside the United States may be different, and purchasing medications in another country should not be encouraged. Eventually, the primary healthcare provider may be notified of this situation, but this is not the initial intervention. Explaining that medical regimens must be followed to remain in the clinic is a threatening comment; the nurse should be the client's advocate in this situation.

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, when the nurse attempts to administer cortisone, the client asks what the medication is and the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? Select all that apply. 1. clients have a right to refuse treatment 2. nurses are required to answer clients truthfully 3. the healthcare provider should have been notified 4. the client had insufficient knowledge to make such a decision 5. legally prescribed medications are administered despite a client's objections

1, 2, 3 rationale: Clients who are mentally competent have the right to refuse treatment; the nurse must respect this right. A client's questions must always be answered truthfully. The healthcare provider should be notified when a client refuses an intervention so that an alternative treatment plan can be formulated. This is done after the nurse explores the client's reasons for refusal. The client had a discussion with the nurse that indicated that the client had sufficient information to make the decision to refuse the medication. The client has a right to refuse treatment; this right takes precedence over the healthcare provider's prescription.

A client who has passed the acute phase of rheumatoid arthritis is permitted to be out of bed as tolerated. After assisting the client out of bed, where should the nurse place the client? 1. low, soft lounge chair 2. straight-back armchair 3. wheelchair with footrests 4. recliner chair with both legs elevated

2 rationale: A straight-back armchair allows the hips and shoulders to be against the back of the chair while fully supporting the thighs. A low, soft lounge chair permits the hips and knees to be flexed greater than 90 degrees, which can cause flexion contractures. The thighs are not fully supported in a wheelchair. A reclining chair with both legs elevated permits the hips to be flexed greater than 90 degrees, which promotes flexion contractures.

A client with rheumatoid arthritis takes aspirin routinely to reduce pain. The client asks whether it is the arthritis, the aspirin, or some other ear problem that causes the bilateral ear buzzing the client is now experiencing. What is an appropriate nursing response? 1. "the ringing in your ears is a sign of an ear infection" 2. "aspirin may have caused some nerve damage in your ear" 3. "accumulation of ear wax causes ringing in the ears" 4. "your symptoms are an expected response to the aging process"

2 rationale: Aspirin may damage the eighth cranial (acoustic) nerve, causing ringing in the ears and impaired hearing. Pain, not ringing in the ears, is a sign of otitis media. Diminished hearing, not ringing, occurs because of mechanical obstruction of the outer ear. Aging may cause decreasing acuity in the extremes of pitch, but it does not cause ringing in the ears.

A client is admitted to the emergency department with joint pain and swelling. Upon assessment the nurse suspects rheumatoid arthritis. Which findings support the nurse's conclusion? Select all that apply. 1. obesity 2. antinuclear antibodies 3. inflammatory disease pattern 4. disease in the bilateral symmetric joints 5. disease in the distal intrapharyngeal joints 6. disease in the weight-bearing joints and hands

2, 3, 4 Rationale: Rheumatoid arthritis is an autoimmune disorder identified by the presence of antinuclear antibodies. Disease in the bilateral symmetric joints is generally seen in rheumatoid arthritis. Rheumatoid arthritis involves inflammation of the joints. Osteoarthritis involves degeneration of the joints. Obesity is a risk factor for osteoarthritis. Osteoarthritis affects weight-bearing joints and the hands.

A client with rheumatoid arthritis calls the outpatient clinic to report that pain with exercising has increased. What should the nurse suggest to the client to decrease pain? 1. "For morning stiffness, take a tub bath rather than a hot shower." 2. "Apply an ice pack directly to the involved joint for no more than 20 minutes at a time." 3. "Decrease the number of repetitions of the exercises." 4. "Cease exercising for a day."

3 rationale: Exercise should be performed to tolerance only; limiting the amount of exercise should decrease pain. To relax the joints, the client should take a hot shower versus a tub bath. Furthermore, it will be difficult for a client with stiff joints to get into a typical bathtub. Ice should never be placed against the skin without a layer of protection; further damage or frostbite could occur. Ceasing exercise for a day will increase stiffness.

A regimen of rest, exercise, and physical therapy is prescribed for a client with rheumatoid arthritis. What should the nurse teach the client is the intended purpose of the regimen? 1. preventing arthritic pain 2. halting the inflammatory process 3. preventing the crippling effects of the disease 4. providing for the return of joint motion after prolonged loss

3 rationale: Range-of-motion exercises are instituted to maintain mobility of joints. Balanced activity and rest will promote resolution of the inflammation. Pain may persist but cannot be allowed to legitimize inactivity. Activity will not prevent the inflammatory process; it may aggravate it. Severely damaged joints may require prosthetic replacement.

The nurse is caring for a postpartum client with a history of rheumatic heart disease. The nurse plans care for this client with what knowledge regarding this client? 1. she should increase her oral fluid intake 2. she should maintain bed rest for a minimum of 4 days 3. she is out of immediate danger, because the stress associated with pregnancy is over 4. she requires monitoring during the first 48 hours because of the stress on the cardiopulmonary system

4 rationale: The blood volume was increased during pregnancy. The rapid fluid shift after the placenta is expelled causes hypervolemia, which increases the workload of the heart, making the first 48 postpartum hours crucial. Increasing the client's oral fluid intake is not recommended, because it will further increase the circulating blood volume and necessitate an increased cardiac output. Progressive ambulation as tolerated is recommended. It takes 48 hours after the birth for the stress of childbearing to be minimized.