NUR302 - Chapter 39: Assessment and Management of Patients With Rheumatic Disorders

A client who was diagnosed with scleroderma 2 years ago is withdrawn, does not look at the nurse, and asks to be left alone. An appropriate nursing diagnosis for the client is:

Disturbed body image The client is exhibiting defining characteristics of disturbed body image.

Which is an appropriate nursing intervention in the care of the client with osteoarthritis?

Encourage weight loss and an increase in aerobic activity Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening, are important approaches to pain management. Clients should be assisted to plan their daily exercise at a time when the pain is least severe, or plan to use an analgesic, if appropriate, before an exercise session. Gastrointestinal complications, especially bleeding, are associated with the use of nonsteroidal anti-inflammatory drugs. Topical analgesics such as capsaicin and methylsalicylate may be used for pain management.

The client with rheumatoid arthritis has a red blood cell count of 3.2 cells/cu mm. Which nursing diagnosis has the highest priority for the client?

Fatigue Low red blood cell count can be related to inadequate nutrition. Insufficient RBC levels compromise the oxygen-carrying capacity of the blood, which can lead to fatigue.

The client with rheumatoid arthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?

Reports increased fatigue Fatigue is common with rheumatoid arthritis. Finding a balance between activity and rest is an essential part of the therapeutic regimen.

The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about?

Methotrexate (Rheumatrex) Methotrexate is a DMARD that reduces the amount of joint damage and slows the damage to other tissues as well. Etanercept and Infliximab are TNF-alpha inhibitors that reduce pain and inflammation. Methylprednisolone is a steroid to reduce pain and inflammation and slow joint destruction.

A client with an autoimmune disorder tells the nurse they are not sure they understand what an autoimmune disorder is. What would be the nurse's best response?

"An autoimmune disorder is characterized by progressive tissue damage without any verifiable cause." Diseases are considered autoimmune disorders when they are characterized by unrelenting, progressive tissue damage without any verifiable etiology. This makes options A, C, and D incorrect.

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

"It will get better and worse again." The client demonstrates understanding of rheumatoid arthritis if he expresses that it's an unpredictable disease characterized by periods of exacerbation and remission. There's no cure for rheumatoid arthritis, but symptoms can be managed. Surgery may be indicated in some cases.

The nurse is teaching a client about rheumatic disease. What statement best helps to explain autoimmunity?

"Your symptoms are a result of your body attacking itself." In autoimmunity, the body mistakes its own tissue for foreign tissue and begins to attack it. Symptoms develop as the body destroys tissue. The body is in effect attacking itself. The other statements do not explain autoimmunity.

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be?

Administering ordered analgesics and monitoring their effects An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management her priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions don't not take priority over pain management.

Which of the following procedures involves a surgical fusion of the joint?

Arthrodesis An arthrodesis is a surgical fusion of the joint. Synovectomy is the excision of the synovial membrane. Tenorrhaphy is the suturing of a tendon. An osteotomy alters the distribution of the weight within the joint.

A patient is being placed on a purine-restricted diet. What food should be suggested by the nurse?

Dairy products Primary hyperuricemia may be caused by severe dieting or starvation, excessive intake of foods that are high in purines (shellfish, organ meats), or heredity.

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included?

Delaying exercise for at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided. A client with osteoarthritis has increased stiffness in the morning upon awakening. Exercise should be scheduled at least 1 hour after awakening. Exercising in the evening interferes with the client's ability to rest at bedtime.

A client with rheumatoid arthritis is prescribed a tumor necrosis factor (TNF)-alpha inhibitor. Which of the following might be prescribed?

Etanercept Etanercept is an example of a tumor necrosis factor (TNF)-alpha inhibitor used to treat rheumatoid arthritis. Diclofenac and indomethacin are nonsteroidal anti-inflammatory drugs (NSAIDs). Celecoxib is a cyclooxygenase-2 (COX-2) inhibitor.

Nursing assessment findings reveal joint swelling and tenderness of the great toe. The nurse suspects which of the following?

Gout Joint swelling and tenderness of the great toe and tophi are classic manifestations of gout.

A patient arrives at the clinic with complaints of pain in the left great toe. The nurse assesses a swollen, warm, erythematous left great toe. What does the nurse determine that the symptoms are most likely related to?

Gout The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of patients) in gout. The abrupt onset often occurs at night, awakening the patient with severe pain, redness, swelling, and warmth of the affected joint.

Which of the following suggests to the nurse that the client with systemic lupus erythematous is having renal involvement?

Hypertension Hypertension is suggestive of renal damage in the client with systemic lupus erythematous.

Which nursing diagnosis is least appropriate for the client with rheumatoid arthritis?

Imbalanced nutrition: greater than body requirements Since weight maintenance/gain is often part of the management plan for the client with rheumatoid arthritis a diagnosis of imbalanced nurtrition: greater than body requirements is the least appropriate. Deficient knowledge: symptom management, impaired physical mobility, and chronic pain are all appropriate nursing diagnoses for a client with rheumatoid arthritis.

Scleroderma typically begins with the involvement of which system?

Integumentary Scleroderma begins with skin involvement. The disease does not begin with respiratory, urinary, or cardiovascular involvement.

The nurse is educating the patient with gout about ways to prevent reoccurrence of an attack. What foods should the nurse encourage the patient to avoid?

Liver Severe dietary restriction is not necessary; however, the nurse encourages the patient to restrict consumption of foods high in purines, especially organ meats, and to limit alcohol intake.

Which of the following would the nurse most commonly assess in a client with ankylosing spondylitis?

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

An arthrocentesis is done to remove synovial fluid from a joint. Synovial fluid from an inflamed joint is characteristically:

Milky, cloudy, and dark yellow. An arthrocentesis shows abnormal synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement.

Which is the leading cause of disability and pain in the elderly?

Osteoarthritis (OA) Osteoarthritis is the leading cause of disability and pain in the elderly. RA, SLE, and scleroderma are not leading causes of disability and pain in the elderly.

A client is diagnosed with systemic lupus erythematosus (SLE). Which of the following would be most appropriate for the nurse to use to evaluate the client's stage of disease?

Review the client's medical record. The nurse evaluates the stage of SLE and plans appropriate interventions by reviewing the medical record and diagnostic findings of the client. The stage of the disease cannot be established by observing the client's gait, inspecting the client's mouth, or auscultating the client's lung sounds.

Which of the following disorders is characterized by an increased autoantibody production?

Systemic lupus erythematosus (SLE) SLE is an immunoregulatory disturbance that results in increased autoantibody production. Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage?

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

Which drug is not used in the treatment of rheumatoid arthritis?

allopurinol Allopurinol is used in the treatment of gout. Etanercept, adalimumab, and methotrexate are all used in the treatment of rheumatoid arthritis.

Fibromyalgia is a common condition that involves

chronic fatigue, generalized muscle aching, and stiffness. Fibromyalgia is a common condition that involves chronic fatigue, generalized muscle aching, and stiffness. The cause is unknown, and no pathological characteristics specific for the condition have been identified. Treatment consists of attention to the specific symptoms reported by the client. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants are used to improve or restore normal sleep patterns, and individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in these individuals.

The nurse is reviewing the medication administration record of the client. Which of the following medications would lead the nurse to suspect that the client is suffering from an acute attack of gout?

colchicine Colchicine is prescribed for the treatment of an acute attack of gout.

Osteoarthritis is known as a disease that

is the most common and frequently disabling of joint disorders. The functional impact of osteoarthritis on quality of life, especially for elderly clients, is often ignored. Reiter syndrome is a spondyloarthropathy that affects young adult males and is characterized primarily by urethritis, arthritis, and conjunctivitis. Psoriatic arthritis, characterized by synovitis, polyarthritis, and spondylitis, requires early treatment because of early damage caused by disease. Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues, making them rigid and decreasing mobility; it is usually diagnosed in the second or third decade of life.

Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia

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

A client with rheumatoid arthritis has experienced increasing pain and progressing inflammation of the hands and feet. What would be the expected goal of the likely prescribed treatment regimen?

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

In teaching clients with osteoarthritis about their condition, it would be important for the nurse to focus on:

Strategies for remaining active Exercise is important for pain and disease management.

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

The belief is that it is an autoimmune disorder with an unknown trigger. Systemic lupus erythematosus is believed to be an autoimmune disorder but the triggering mechanism is not known. The disorder is more common in women than in men, most with the disorder in the 3rd or 4th decade of life. The disease is considered the "great imitator" because the clinical signs resemble many other conditions. SLE is a diffuse connective tissue disease that affects multiple body systems.

The presence of crystals in synovial fluid obtained from arthrocentesis is indicative of

gout. The presence of crystals is indicative of gout, whereas the presence of bacteria is indicative of infective arthritis.

The nurse is assessing a patient with a diagnosis of scleroderma. What clinical manifestations of scleroderma does the nurse assess? (Select all that apply.)

- Decreased ventilation owing to lung scarring - Dysphagia owing to hardening of the esophagus - Dyspnea owing to fibrotic cardiac tissue 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.

Which of the following would a nurse encourage a client with gout to limit?

Purine-rich foods Clients with gout should be advised to have adequate protein with the limitation of purine-rich foods to avoid contributing to the underlying problem. The diet should also be relatively high in carbohydrates and low in fats because carbohydrates increase urate excretion and fats retard it. A high fluid intake is recommended because it helps increase the excretion of uric acid.

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?

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

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?

For their immunosuppressant effects Drug therapy using antiinflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of infection; an autoimmune disease is not a neoplastic disease. Drugs are not ordered just so the client has strong drug therapy.

The nurse teaches the client that the presence of crystals in the synovial fluid obtained from arthrocentesis confirms which disease process?

Gout The presence of crystals is indicative of gout; the presence of bacteria is indicative of infective arthritis.

The client with osteoarthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?

Has a weight gain of 5 pounds Obesity is a risk factor for osteoarthritis. Excess weight is a stressor on the weight-bearing joints. Weight reduction is often a part of the therapeutic regimen.

A client is recovering from an attack of gout. Client teaching should include the need to lose weight because:

weight loss will reduce uric acid levels and reduce stress on joints. Weight loss will reduce uric acid levels and reduce stress on joints. Weight loss won't reduce purine levels, reduce inflammation or increase uric acid levels.

Which joint is most commonly affected in gout?

Metatarsophalangeal The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of clients); this is referred to as podagra. The wrists, fingers, and elbows are less commonly affected. The tarsal area, ankle, and knee are not the most commonly affected in gout.

A nurse should advise a patient with gout to avoid which of the following foods?

Organ meats and scallops An excessive intake of foods that are high in purines (shellfish, organ meats) may result in symptoms of gout in susceptible persons. A diet low in purine is recommended.

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?

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

A client with early stage rheumatoid arthritis asks the nurse what they can do to help ease the symptoms of their disease. What would be the best response by the nurse?

"The doctor could prescribe anti-inflammatory drugs." Drug therapy using antiinflammatory 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 immune abnormalities that characterize systemic lupus erythematosus (SLE) include which of the following? Select all that apply.

- Susceptibility - Abnormal innate and adaptive immune responses - Autoantibodies immune complexes - Inflammation - Damage The immune abnormalities that characterize SLE occur in five phases: susceptibility, abnormal innate and adaptive immune responses, autoantibodies immune complexes, inflammation, and damage.

Azathioprine (Imuran) has been prescribed for the client with severe rheumatoid arthritis. The dose prescribed is 2 mg/kg/day orally in two divided doses. The medication available is a 50-mg scored tablet. The client weighs 110 pounds. How many milligrams will the nurse prepare per dose for the client?

50 The client weighs 50 kg (110 lbs/2.2 lbs per kg). The client will receive 100 milligrams per day (50 kg x 2 milligrams/kg). The medication is to be given in two divided doses or 50 mg per dose.

Which client is most likely to develop systemic lupus erythematosus (SLE)?

A 27-year-old black female SLE strikes nearly 10 times as many women as men and is most common in women between ages 15 and 40. SLE affects more black women than white women; its incidence is about 1 in every 250 black women, compared to 1 in every 700 white women.

The nurse is caring for a client with rheumatoid arthritis who suffers with chronic pain in the hands. When would be the best time for the nurse to perform range-of-motion exercises?

After the client has had a warm paraffin hand bath Whether resting or moving, clients in this stage of the disease have considerable chronic pain, which typically is worse in the morning after a night's rest. Warmth helps decrease the symptoms of pain and will be the best time to perform range of motion exercises.

Which of the following clinical manifestations would the nurse expect to find in a client with osteoarthritis?

Early morning stiffness Osteoarthritis is characterized by early morning stiffness that decreases with activity.

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

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

Which finding is consistent with the diagnosis of rheumatoid arthritis?

Cloudy synovial fluid In a client with rheumatoid arthritis, arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement.

A nurse should expect to administer which medication to a client with gout?

Colchicine A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps, it doesn't treat gout.

The treatment of gout involves managing the acute inflammatory stage, preventing flare-ups, and controlling hyperuricemia. Select the agent of first choice when an acute inflammatory attack begins.

Colchicine Colchicine, along with indomethacin, ibuprofen, or a corticosteroid is prescribed to relieve an acute attack of gout. Benemid and Anturane increase the urinary excretion of uric acid, and Aloprim breaks down purines before uric acid is formed.

When caring for a client experiencing an acute gout attack, the nurse anticipates administering which medication?

Colchicine The physician usually orders colchicine for a client experiencing an acute gout attack. This drug decreases leukocyte motility, phagocytosis, and lactic acid production, thereby reducing urate crystal deposits and relieving inflammation. Allopurinol is used to decrease uric acid production in clients with chronic gout. Although corticosteroids are ordered to treat gout, the nurse wouldn't give them because they must be administered interarticularly to this client. Propoxyphene, an opioid, may be used to treat osteoarthritis.

Which of the following is a plasma protein associated with the immunologic reaction?

Complement Complement is a plasma protein associated with immunologic reactions. Leukotrienes are chemical mediators from constituents of cell membranes. Cytokines are nonantibody proteins that act as intercellular mediators, as in the generation of the immune response. Prostaglandins are lipid-soluble molecules synthesized from constituents of cell membranes.

The diagnosis of osteoarthritis (OA) depends on evaluation of a number of factors. A nurse understands that the first, and frequently only, sign of symptomatic OA is which of the following?

Degree of limited passive movement OA is typically diagnosed by an overall clinical impression based on the patient's age and history, location of joint abnormalities, and radiographic findings. Limited passive movement can be the first and only physical sign of symptomatic OA.

A client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse not include when teaching the client and family information about managing the disease?

If you have problems with a medication, you may stop it until your next physician visit. Take medications exactly as directed and do not stop the medication if symptoms are relieved unless advised to do so by the physician. Sunlight tends to exacerbate the disease. Because fatigue is a major issue, allow for adequate rest, along with regular activity to promote mobility and prevent joint stiffness. Maintain a well-balanced diet and increase fluid intake to raise energy levels and promote tissue healing.

Which nursing diagnosis is most inappropriate for the client with osteoarthritis?

Imbalanced nutrition: less than body requirements Weight reduction is often part of the management plan for the client with osteoarthritis.

Which findings best correlate with a diagnosis of osteoarthritis?

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

Which condition is the leading cause of disability and pain in the elderly?

Osteoarthritis (OA) OA is the leading cause of disability and pain in the elderly. RA, SLE, and scleroderma are not leading causes of disability and pain in the elderly.

Which of the following is the definitive diagnostic of gouty arthritis?

Polarized light microscopy of the synovial fluid A definitive diagnosis of gouty arthritis is established by polarized light microscopy of the synovial fluid of the involved joint. Synovial biopsy, arthrocentesis, and radiological studies aid in the diagnosis of rheumatoid arthritis.

A patient with an acute exacerbation of arthritis is temporarily confined to bed. What position can the nurse recommend to prevent flexion deformities?

Prone It is best for the patient with rheumatoid arthritis to lie prone several times daily to prevent hip flexion contracture.

A patient comes to the clinic with an inflamed wrist. How should the nurse splint the joint to immobilize it?

Slight dorsiflexion Devices such as braces, splints, and assistive devices for ambulation (e.g., canes, crutches, walkers) ease pain by limiting movement or stress from putting weight on painful joints. Acutely inflamed joints can be rested by applying splints to limit motion. Splints also support the joint to relieve spasm.

A patient is taking NSAIDs for the treatment of osteoarthritis. What education should the nurse give the patient about the medication?

Take the medication with food to avoid stomach upset. The nurse should advise the patient to take NSAIDs with food to avoid stomach upset.

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

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

A nurse is assessing a client with possible osteoarthritis. The most significant risk factor for primary osteoarthritis is:

age. 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 client was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. What would not be a part of teaching plan for this condition?

applications of ice Application of ice is not part of the treatment regimen. Encouraging the client to eat a healthy diet, avoiding caffeine and alcohol, regular exercise, and stress reduction are part of the teaching plan.

A client with gout has been advised to lose weight. She informs the nurse that she plans to go on a "guaranteed rapid weight loss" plan that involves fasting and heavy exercise. Which response would be most appropriate?

"There might be some difficulties with your plan and fasting." Clients should avoid fasting, low-carbohydrate diets, and rapid weight loss because these measures increase the likelihood of ketone formation, which inhibits uric acid excretion. Gradual weight loss helps reduce serum uric acid levels in clients with gout.

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?

Tricyclic antidepressants 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 patient is seen in the office for complaints of joint pain, swelling, and a low-grade fever. What blood studies does the nurse know are consistent with a positive diagnosis of RA? (Select all that apply.)

- Positive C-reactive protein (CRP) - Positive antinuclear antibody (ANA) - Red blood cell (RBC) count of <4.0 million/mcL Several assessment findings are associated with RA: rheumatoid nodules, joint inflammation detected on palpation, and laboratory findings. The history and physical examination focuses on manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tend to be significantly elevated in the acute phases of RA and are therefore useful in monitoring active disease and disease progression. The red blood cell count and C4 complement component are decreased. Antinuclear antibody (ANA) test results may also be positive.

The nurse is educating a patient about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms they should report. Which COX-2 inhibitor is the nurse educating the patient about?

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

A nurse assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?

Facial erythema, pericarditis, pleuritis, fever, and weight loss An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE.

When developing a care plan for a client newly diagnosed with scleroderma, which nursing diagnosis has the highest priority?

Impaired skin integrity Impaired skin integrity is a concern for the client with scleroderma in its earlier stages. Meticulous skin care is required to prevent complications. Although Risk for constipation may also be appropriate, this nursing diagnosis isn't the priority. Clients with scleroderma are at risk for Imbalanced nutrition: Less than body requirements. The client with advanced scleroderma, not newly diagnosed scleroderma, is at increased risk for developing respiratory complications.

A nursing student asks the instructor how to identify rheumatoid nodules in a client with rheumatoid arthritis. Which of the following characteristics would the instructor include?

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

A client with ankylosing spondylitis has a stooped position and is being positioned in the bed prior to the nurse taking vital signs. The nurse listens to the client's lungs after positioning. What finding does the nurse hear when listening to lung sounds?

Lung sounds are diminished in the apical area. The lumbar curve of the spine may flatten. The neck can be permanently flexed, and the client appears to be in a perpetual stooped position. Aortic regurgitation or atrioventricular node conduction disturbances may occur. Lung sounds may be reduced, especially in the apical area. The nurse would not hear rhonchi, crackles, or a pericardial friction rub unless the client had underlying cardiac or respiratory disorders.

A client with rheumatoid arthritis reports joint pain. What intervention is a priority to assist the client?

Nonsteroidal anti-inflammatory drugs 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.

Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues?

Scleroderma Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. SLE is an immunoregulatory disturbance that results in increased autoantibody production. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

The nurse is teaching the client newly diagnosed with systemic lupus erythematous about the condition. Which statement by the client indicates teaching was effective?

"I should avoid prolonged sun exposure." Prolonged exposure to sun and ultraviolet light can cause exacerbations and disease progression.

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?

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

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

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

Which of the following classifications are considered antiarthritic drugs? Select all that apply.

- Anti-inflammatory - Disease-modifying antirheumatics (DMARDs) - Glucocorticoids Antiarthritic drugs fall into three major groups: nonsteroidal anti-inflammatory drugs (NSAIDs), DMARDs, and glucocorticoids. Diuretics and muscle relaxants are not antiarthritic drugs.

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.

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

The nurse is performing discharge teaching for a client with rheumatoid arthritis. What teachings are priorities for the client? Select all that apply.

- Safe exercise - Medication dosages and side effects - Assistive devices 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.

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 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 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?

An exercise routine that includes range-of-motion (ROM) exercises 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.

Which term refers to fixation or immobility of a joint?

Ankylosis Ankylosis may result from disease or scarring due to trauma. Hemarthrosis refers to bleeding into a joint. Diarthrodial refers to a joint with two freely moving parts. Arthroplasty refers to replacement of a joint.

Which of the following refers to fixation of a joint?

Ankylosis Fixation of a joint, called ankylosis, eliminates friction, but at the drastic cost of immobility. Inflammation is manifested in the joints as synovitis. Pannus has a destructive effect on the adjacent cartilage and bone. Articulations are joints.

The nurse intervenes to assist the client with fibromyalgia to cope with which symptoms?

Chronic fatigue, generalized muscle aching, and stiffness Fibromyalgia is a common condition that involves chronic fatigue, generalized muscle aching, and stiffness. The cause is unknown, and no pathologic characteristics specific for the condition have been identified. Treatment consists of attention to the specific symptoms reported by the client. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants are used to improve or restore normal sleep patterns, and individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in these individuals.

A client comes to the emergency department complaining of pain in the right leg. When obtaining the history, the nurse learns that the client has a history of obesity and hypertension. Based on this information the nurse anticipates the client having which musculoskeletal disorder?

Degenerative joint disease Obesity predisposes the client to degenerative joint disease. Obesity isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease.

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. Which of the following would the nurse expect to find?

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

A client is complaining of severe pain in the left great toe. What lab studies that the nurse reviews indicate that the client may have gout?

Elevated uric acid levels Gout is characterized by hyperuricemia (accumulation of uric acid in the blood) caused by alterations in uric acid production, excretion, or both. An elevated white blood count may be indicative of any inflammatory response and is not specific to gout. A decreased hemoglobin and hematocrit may indicate bleeding from somewhere in the body. Increased AST and ALT would indicate liver dysfunction.

The nursing instructor is talking with the junior nursing class about autoimmune disorders. What disease process would the instructor name as an autoimmune disorder?

Fibromyalgia Some believe that CFS is associated with fibromyalgia, pain in fibrous tissues of the body such as muscles, ligaments, and tendons, because both conditions share many symptoms. Multiple myeloma is a neoplastic disease. Options B and D are distractors for the question.

A client who has been diagnosed with osteoarthritis asks if he'll eventually begin to notice deformities in his hands and fingers as the condition progresses. Which concept should the nurse include in her response?

Hand and finger deformities are associated with the development of rheumatoid arthritis. The nurse should explain to the client that joint deformities occur with rheumatoid arthritis, not osteoarthritis. Osteoarthritis typically follows a pattern of cartilage destruction and increased pain. The nurse is part of the interdisciplinary health care team and is capable of answering the client's questions about the typical progression of disease.

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?

Hyperuricemia Gout is caused by hyperuricemia (increased serum uric acid).

Which points should be included in the medication teaching plan for a client taking adalimumab?

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

A client with degenerative joint disease asks the nurse for suggestions to avoid unusual stress on the joints. Which suggestion would be most appropriate?

Maintain good posture. The nurse needs to remind the client with degenerative joint disease to maintain good posture. While the client need not maintain complete bed rest, performing aerobic exercises is not advisable as it may place undue stress on the joint worsening the condition. Shifting weight from one foot to the other does not help avoid unusual stress on a joint.

Which of the following is the most common cause for a patient to seek medical attention for arthritis?

Pain The symptom that most commonly causes a person to seek medical attention is pain. Other common symptoms include joint swelling, limited movement, stiffness, weakness, and fatigue.

A client has had several diagnostic tests to determine if he has systemic lupus erythematosus (SLE). What result is very specific indicator of this diagnosis?

Positive Anti-dsDNA antibody test Anti-double-stranded DNA (anti-dsDNA) antibody test is a test that shows high titers of antibodies against native DNA. This is very specific for SLE because this test is not positive for other autoimmune disorders. Anti-Smith (anti-Sm) antibodies are specific for SLE, but are found in only 20% to 30% of clients with SLE. ANA titre shows the presence of an autoimmune disease but is not specific to SLE. The other lab studies may also indicate multisystem involvement.

Primary gout is often caused by an inherited disorder in which type of metabolism?

Purine Primary gout is often caused by an inherited disorder in purine metabolism. Primary gout is not a disorder of altered carbohydrate, fat, or glucose metabolism.

The nurse knows that a patient who presents with the symptom of "blanching of fingers on exposure to cold" would be assessed for what rheumatic disease?

Raynaud's phenomenon Blanching of fingers on exposure to cold is associated with Raynaud's phenomenon.

A nurse is poviding care for a client with progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?

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

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

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

The nurse is gathering objective data for a client at the clinic complaining of arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. What does the nurse recognize this deformity as?

Swan neck deformity A swan neck deformity is a hyperextension of the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. A Boutonnière deformity is a persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint. Ulnar deviation is when the fingers are deviating laterally toward the ulna. A rheumatoid nodule is a subcutaneous nodule.

Which disorder is characterized by a butterfly-shaped rash across the bridge of the nose and cheeks?

Systemic lupus erythematosus (SLE) 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.

Which newer pharmacological therapy, used to treat osteoarthritis, is thought to prevent the loss of cartilage and repair chondral defects, as well as have some anti-inflammatory effects?

Viscosupplementation Viscosupplementation, the intra-articular injection of hyaluronates, is thought to prevent the loss of cartilage and repair chondral defects. It may also have some anti-inflammatory effects. Glucosamine and chondroitin are thought to improve tissue function and retard breakdown of cartilage. Capsaicin is a topical analgesic.

Which of the following would the nurse expect to assess as the most common finding associated with fibromyalgia?

Widespread chronic pain The most common finding associated with fibromyalgia is widespread and chronic pain. Heberden nodes are associated with osteoarthritis. Jaw locking is a manifestation of temporomandibular joint dislocation. A butterfly facial rash is associated with systemic lupus erythematosus.

A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include:

administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program. NSAIDs are routinely used for anti-inflammatory and analgesic effects. NSAIDs reduce inflammation, which causes pain. Opioids aren't used for pain control in osteoarthritis. Intra-articular injection of corticosteroids is used cautiously for an immediate, short-term effect when a joint is acutely inflamed. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.

A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to:

combat inflammation. Corticosteroids are used to combat inflammation in a child with SLE. To prevent infection, the physician would order antibiotics. Aspirin is used to prevent platelet aggregation. Diuretics, not corticosteroids, promote diuresis.

A client is being treated for hyperuricemia. Part of the treatment strategy is for the client to avoid contributing factors whenever possible. Which activities might bring on an acute attack?

eating organ meats and sardines During an acute attack, high-purine foods are avoided, including organ meats, gravies, meat extracts, anchovies, herring, mackerel, sardines, and scallops. The other listed factors do not worsen attacks.

A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of:

organ meats. Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, chocolate, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis.

The nurse teach the client that osteoarthritis is

the most common and frequently disabling of joint disorders. The functional impact of osteoarthritis on quality of life, especially for elderly clients, is often ignored. Reiter syndrome is a spondyloarthropathy that affects young adult males and is characterized primarily by urethritis, arthritis, and conjunctivitis. Psoriatic arthritis, characterized by synovitis, polyarthritis, and spondylitis, requires early treatment because of early damage caused by disease. Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues and is usually diagnosed in the second or third decade of life.

What intervention is a priority for a client diagnosed with osteoarthritis?

Physical therapy and exercise Clients with osteoarthritis need to maintain joint mobility. To preserve joint function, individuals need to learn appropriate activities. Colchicine and allopurinol are used for gout, not osteoarthritis. Hydrotherapy is not a priority for care.

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. She asks which of the tests ordered will determine if she is positive for the disorder. Which statement by the nurse is most accurate?

"The diagnosis won't be based on the findings of a single test but by combining all data found." There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the physician, stating that SLE is a serious systemic disorder, and asking the client to express her feelings about the potential diagnosis don't answer the client's question.

Which of the following statements is accurate regarding osteoarthritis?

It is a noninflammatory disorder and the most common and frequently disabling of joint disorders. Osteoarthritis (OA), also known as degenerative joint disease, is a chronic, noninflammatory (even though inflammation may be present), progressive disorder that causes cartilage deterioration in synovial joints and vertebrae. OA is the most common and most frequently disabling of the joint disorders that is overdiagnosed and trivialized and frequently over or undertreated. Aging is the risk factor most strongly correlated with OA. Gout is caused by an overproduction of uric acid. Rheumatoid arthritis is the most common inflammatory arthritic disorder.

A patient is suspected of having myositis. The nurse prepares the patient for what procedure that will confirm the diagnosis?

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