Patho Ch 44 Disorders of Skeletal System Metabolic

A 55-year-old male client has reported joint pain in his feet. Which of the following blood work results should prompt further testing to rule out primary gout? A. Increased C-reactive protein (CRP) B. Increased serum uric acid C. Increased polymorphonuclear leukocytes D. Increased serum cortisol

B Although hyperuricemia is not diagnostic of gout, it is suggestive and should prompt further assessment. Increases in CRP, polymorphonuclear leukocytes, and cortisol levels are not as closely associated with the body's response to gout.

For many clients, the first indication that they have osteoporosis is: A. Bone pain that is not alleviated by rest B. A bone fracture C. Craving high-calcium foods D. Decrease in range of motion in the hip and knee joints

B Osteoporosis is usually a silent disorder. Often, the first manifestations of the disorder are those that accompany a skeletal fracture—a vertebral compression fracture or fracture of the hip, pelvis, humerus, or other bones. The onset of the disease is not typically marked by pain or decreased range of motion. Clients with osteoporosis are not noted to crave foods that are high in calcium.

Disorders that affect cortical bone typically result in: A. Fractures of long bones B. Impaired collagen synthesis C. Infection D. Vertebral fractures

A Disorders in which cortical bone is defective or reduced in mass lead to fractures of the long bones, whereas those of cancellous bone lead preferentially to vertebral fractures. Neither process directly causes impaired collagen synthesis or infection.

When comparing a child's clinical manifestations with that of oligoarthritis versus systemic onset, the health care provider diagnoses this in your 4-year-old child with oligoarthritis based on which of the following clinical findings? A. Right knee is warm and painful when putting it through normal range of motion. B. Faint, red macular rash noted over entire body. C. Rash is diffuse with severe itching. D. Daily has an intermittent elevated temperature.

A Oligoarthritis, which is the most common type of JIA, predominantly affects joints of the lower extremities, usually the knees or ankle. Involvement of upper extremity large joints and the hip is rarely a presenting sign. Often a single joint is affected at onset. Children with this form of JIA are usually younger (1 to 5 years at onset) and are often rheumatoid factor (RF) positive. The symptoms of systemic JIA include a daily intermittent high fever, which usually is accompanied by a characteristic faint, erythematous, macular rash. The rash is not pruritic.

A feature of rheumatoid arthritis that differentiates it from other forms of inflammatory arthritis is the development of: A. Pannus tissue B. Tophus deposits C. Subluxations D. Autoantibodies

A Pannus is a feature of rheumatoid arthritis that differentiates it from other forms of inflammatory arthritis. Pannus, destructive vascular granulation tissue, extends from the synovium to involve the unprotected bone at the junction between cartilage and subchondral bone. Systemic lupus erythematosus (SLE) is characterized by the formation of autoantibodies and immune complexes. RA and SLE are characterized by subluxation of the carpometacarpal joint and other joints. With acute gouty arthritis, there are recurrent attacks of severe articular and periarticular inflammation, resulting in tophus formation (accumulation of crystalline deposits) in articular surfaces, bones, soft tissue, and cartilage.

An elderly female complains about waking up one morning with pain/stiffness in her neck/shoulders. Lab work reveals an elevated erythrocyte sedimentation rate (ESR). The physician gives the client a 3-day trial of prednisone, which significantly improves the pain. The health care provider correlates this information and diagnoses which of the following disorders? A. Polymyalgia rheumatica B. Psoriatic arthritis C. Reiter syndrome D. Ankylosing spondylitis

A Polymyalgia rheumatica is a common syndrome of older clients, rarely occurring before 50 years and usually after 60 years of age. Reiter syndrome, psoriatic arthritis, and ankylosing spondylitis may occur at younger ages.

A client presents to the pain clinic for a steroid injection into the spine due to increasing pain around the joints. The health care provider tells the client, "You have inflammation where your tendons/ligaments insert into the bone. This injection should help." The nurse assisting with the procedure recognizes this to be characteristic of: A. Sacroiliitis B. Calcinosis C. Excessive bone turnover D. Autoimmune etiology

A Sacroiliitis is a pathologic hallmark of the spondyloarthropathies. Calcinosis is associated with scleroderma. The spondyloarthropathies do not involve bone turnover, and an autoimmune etiology has not been demonstrated.

While explaining the physiology behind systemic sclerosis (scleroderma), the instructor states, "One of the hallmarks of scleroderma is: A. Activation of fibroblasts, resulting in fibrosis B. The development of thin fragile skin C. Development of a collagen deficiency D. Avascular necrosis of the femoral head

A Systemic sclerosis, sometimes called scleroderma, is an autoimmune disease of connective tissue characterized by excessive collagen deposition in the skin (with fibrotic thickening) and internal organs, such as the lungs, gastrointestinal tract, heart, and kidneys. Almost all persons with scleroderma develop polyarthritis and Raynaud phenomenon. Musculoskeletal manifestations of systemic lupus erythematosus (SLE), rather than systemic sclerosis, include rupture of the intrapatellar and Achilles tendons and avascular necrosis, frequently of the femoral head. RA granulomatous lesions have a central core of fibrinoid necrosis that is made up of a mixture of fibrin and other proteins such as degraded collagen.

When explaining to the client diagnosed with gout how the xanthine oxidase inhibitors work to help treat gout, the health care provider would include which of the following data? Allopurinol: A. Blocks the production of uric acid by the body B. Increases elimination of uric acid by the kidneys C. Prevents flare-up during the first few months of starting medication D. Can be given intravenously to rapidly decrease serum uric acid levels

A Xanthine oxidase inhibitors block the synthesis of uric acid. In this classification, the most commonly prescribed to lower urate levels is allopurinol. The uricosuric agents prevent the tubular reabsorption of urate and increase its excretion in the urine. Uricase agents convert insoluble uric acid to a soluble product than can be excreted easily. Pegloticase is an infusible uricase agent that works rapidly to reduce serum uric acid.

A clinic nurse plans care for a newly diagnosed osteoarthritis client. Which of the following items should this client be provided with educational materials? Select all that apply. A. Splints to protect and rest the involved joint B. Use of heat and cold when appropriate for muscle spasms and pain C. How to use a cane or walker if hip/knees joints are involved D. High dose of daily glucosamine and chondroitin E. Narcotics to help control nighttime pain

A, B, C Physical measures are aimed at improving the supporting structures of the joint and strengthening opposing muscle groups involved in cushioning weight-bearing forces. This includes a balance of rest and exercise, use of splints to protect and rest the joint, use of heat and cold to relieve pain and muscle spasm, and adjusting the activities of daily living. The involved joint should not be further abused, and steps should be taken to protect and rest it. These include weight reduction (when weight-bearing surfaces are involved) and the use of a cane or walker if the hips and knees are involved. A recent multicenter trial funded by the National Institutes of Health found that glucosamine and chondroitin (alone or in combination) were no better than placebo in reducing pain in the total group of persons with knee pain. Narcotics are usually not the pain medication of choice for OA.

A client presents to the orthopedic clinic for evaluation since the primary care provider thinks the client may have rheumatoid arthritis (RA). Which statement by the client correlates with the diagnosis of RA? Select all that apply. A. "I'm having a hard time opening doors since it hurts so bad." B. "Look, I didn't button all my shirt buttons...it just hurts too much and look at the swelling in my hands." C. "Look how my hand is deformed. My doctor calls it 'hyperextension.'" D. "Just look at my face. It looks like I have varicose veins on my cheeks."

A, B, C Rheumatoid arthritis (RA) joint involvement usually is symmetric and polyarticular. Pain with turning door knobs, opening jars, and buttoning shirts is commonly reported due to swelling of the wrists and small joints of the hand. Hyperextension of the PIP joint and partial flexion of the distal interphalangeal (DIP) joint is called a swan neck deformity. As the RA inflammatory process progresses, synovial cells and subsynovial tissues undergo reactive hyperplasia. With osteoarthritis (OA), joint changes result from the inflammation caused when the cartilage attempts to repair itself, creating osteophytes or spurs. Raynaud phenomenon (a vascular disorder characterized by reversible vasospasm of the arteries supplying the fingers) and telangiectasia (dilated skin capillaries) are characteristic of scleroderma.

A health care provider suspects a female client (who has had vague complaints over the past several months) may be developing systemic lupus erythematosus (SLE). Which clinical manifestations would correlate with this diagnosis? Select all that apply. A. Arthralgia B. Tendon rupture C. Facial hair growth D. Uncontrolled hypertension related to pyelonephritis E. Chest pain that increases with each deep breath

A, B, E Arthralgias and arthritis are among the most commonly occurring early symptoms of SLE. Pulmonary involvement is manifested primarily by pleural effusions and/or pleuritis. Pleural effusions are typically small, bilateral, and exudative. Up to 50% of persons with SLE develop pleuritis (chest pain that increases with each deep breath), which is manifested by pleuritic chest pain. Later manifestations include rupture of the Achilles tendons, hair loss, and forms of glomerulonephritis (rather than pyelonephritis).

Which of the following clients are at risk for developing osteomalacia? Select all that apply. A. An elderly female who "can't stand to drink milk" and refuses calcium supplements since she has a history of kidney stones B. A person who lives in a colder region of the northwest who doesn't get out much during the winter months for fear of falling C. A middle-aged adult with acute renal insufficiency caused by decreased cardiac output prior to having a coronary bypass graft surgery D. A young 30-year-old African American diagnosed with hypertension who is noncompliant related to taking medication and prescribed diet restrictions E. A female client whose father had a genetic predisposition to primary hyperparathyroidism resulting in increased calcium resorption from the bone

A, B, E In contrast to osteoporosis (which causes a loss of total bone mass), osteomalacia causes defective mineralization but not the loss of bone matrix. The incidence of osteomalacia is high among the elderly because of diets deficient in calcium and vitamin D. Melanin is extremely efficient in absorbing UVB radiation; thus, decreased skin pigmentation markedly reduces vitamin D synthesis. There also is a greater incidence of osteomalacia in the colder regions of the world, particularly during the winter months when UVB radiation is inadequate to allow skin synthesis of vitamin D. Acute renal insufficiency and uncontrolled hypertension do not relate to defective bone mineralization.

A client presented to the emergency department after getting "hit in the head with a baseball" while watching his grandson play. An x-ray of the head reveals poor quality of bone. The ED physician suspects the client has Paget disease. Which of the following signs/symptoms helps confirm this diagnosis? Select all that apply. A. "I've had a lot of headaches lately." B. "Every now and then, I get a ringing in my ears." C. "Do you see my knuckles...they have big growths on them." D. "My thumb joint has been cracking every time I rotate it." E. "I have gotten dizzy and had to sit down while shopping."

A, B, E Skeletal expansion and distortion may be obvious if the disease affects the skull, jaw, clavicle, or long bones of the leg. Involvement of the skull causes headaches, intermittent tinnitus (ringing in the ears), vertigo (dizziness), and eventual hearing loss. The abnormal knuckles and thumb joint are related to arthritis.

Which of the following signs and symptoms should prompt a 29-year-old woman's primary care provider to assess for systemic lupus erythematosus (SLE)? A. Chronic nausea and vomiting that is unresponsive to antiemetics B. Joint pain and increased creatinine and blood urea nitrogen C. A history of thromboembolic events and varicose veins D. Dysmenorrhea and recent spontaneous abortion

B Renal involvement occurs in approximately one half to two thirds of persons with SLE, and arthralgia is a common early symptom of the disease. Although the manifestations of SLE are diffuse, these do not typically include alterations in hemostasis, gastrointestinal symptoms, dysmenorrhea, or miscarriage.

An elderly resident of an assisted-living facility has had his mobility and independence significantly impaired by the progression of his rheumatoid arthritis (RA). What is the primary pathophysiologic process that has contributed to this client's decline in health? A. A mismatch between bone resorption and remodeling B. Immunologically mediated joint inflammation C. Excessive collagen production and deposition D. Cytokine release following mechanical joint injury

B The pathogenesis of RA can be viewed as an aberrant immune response that leads to synovial inflammation and destruction of the joint architecture. Paget disease is caused by abnormal bone resorption and remodeling, whereas collagen deposition underlies scleroderma. Osteoarthritis is believed to be initiated by mechanical injury and subsequent cytokine release.

After numerous trips to the physician's office, a client is diagnosed with diffuse scleroderma based on which of the following clinical manifestations? Select all that apply. A. Protruding eyeball with very red, inflamed eyes and associated photophobia. B. Difficulty swallowing resulting in weight loss due to malabsorption. C. Spider veins on the face and chest. D. Hands turn bluish purple when getting items out of the freezer. E. Inability to walk long distances with severe leg cramping in calf muscles.

B, C, D Some persons with scleroderma have limited involvement and may develop the CREST syndrome, characterized by a combination of calcinosis (i.e., calcium deposits in the subcutaneous tissue that erupt through the skin), Raynaud phenomenon (a vascular disorder characterized by reversible vasospasm of the arteries supplying the fingers), esophageal dysmotility, sclerodactyly (localized scleroderma of the fingers), and telangiectasia (dilated skin capillaries). Protruding eyeball is related to hyperthyroidism, and inability to walk distances without cramping is known as claudication caused by poor circulation.

Which of the following measures should a public health nurse recommend to middle-aged women to reduce their chances of developing osteoporosis later in life? A. Weight control and daily use of low-dose corticosteroids B. Genetic testing and range-of-motion exercises C. Calcium supplementation and regular physical activity D. Increased fluid intake and use of vitamin D supplements

C Although the use of vitamin D supplements may be of preventative value for some clients, the primary prevention measures for osteoporosis include calcium supplementation and regular exercise. Genetic testing and increased fluid intake are not relevant measures, and corticosteroids are a risk factor for osteoporosis.

A female client presents to the orthopedic clinic for evaluation. The primary care provider told her she has a "spur" on her joint. She asks, "Why did this happen? I guess I just didn't exercise enough." The nurse recognizes this to be a later structural change of osteoarthritis (OA), where the client no longer has a "shock absorber," culminating in: A. Osteonecrosis and loss of synovial fluid B. Formation of tophi in the synovial space C. Osteophyte formation and erosion of cartilage D. Separation of the epiphyseal plate

C As OA progresses, cartilage is lost and osteophytes, or spurs, develop on the surface of the articulating bones. Osteonecrosis does not typically develop, and synovial fluid is not lost. Tophi are associated with gout, not OA, and the epiphyseal plate does not separate in the course of OA.

An adult female client visits with her health care provider about pain in her hand. She describes it as an audible grinding and cracking sound, especially in her thumb. "I had to buy an automatic jar opener...I just can't grasp and open a jar...it just hurts too badly." The health care provider suspects the client has a degenerative form of joint disease that is often evidenced by: A. Rheumatoid arthritis B. Systemic lupus erythematosus C. Osteoarthritis D. Ankylosing spondylitis

C In osteoarthritis (OA) syndrome, crepitus and grinding may be evident when the osteoarthritic joint is moved. OA joint enlargement results from new bone formation and the joint feels hard, in contrast to the soft, spongy feeling characteristic of the joint in rheumatoid arthritis (RA). The person with ankylosing spondylitis typically reports low back pain, which becomes worse when resting, particularly when lying in bed. Systemic lupus erythematosus (SLE) is characterized by the formation of autoantibodies and immune complexes (type III hypersensitivity). SLE has the capacity to affect many different body systems, including the musculoskeletal system, skin, cardiovascular system, lungs, kidneys, central nervous system (CNS), and red blood cells and platelets.

A young adult male client presents to the orthopedic clinic complaining of "stiffening of the spine." The health care provider orders some diagnostic lab work. Which lab result leads the health care worker to diagnose ankylosing spondylitis? A. Elevated serum calcium level of 15.1 mg/dL B. Severe decrease in red blood cells associated with decreased iron levels C. Presence of HLA-B27 allele marker D. Elevated serum uric acid level

C The HLA-B27 antigen remains one of the best-known examples of an association between a disease and a hereditary marker; approximately 90% of those with ankylosing spondylitis possess the HLA-B27 antigen. Primary gout is often caused by an inborn error in metabolism and is characterized primarily by hyperuricemia and gout. The person also may have a mild normocytic normochromic anemia but not iron deficiency anemia.

A female athlete has been diagnosed with amenorrhea due to intense training for a spot on the Olympic swimming team. As a health care provider, which of the following should be implemented to prevent premature osteoporosis? A. Encourage a minimum of 10 hours of sleep/night. B. Increase dietary intake of protein and iron. C. Calcium/vitamin D supplements to support BMD. D. Watch sodium intake and eat a carb-consistent diet with lots of fruits.

C The female athlete triad, a pattern of disordered eating that leads to amenorrhea and eventually premature osteoporosis, is being seen increasingly in female athletes because of an increased prevalence of eating disorders. Poor nutrition, combined with intense exercise training, can lead to decrease in the critical body fat-to-muscle ratio needed for normal menses and estrogen production by the ovary. The lack of estrogen combined with the lack of calcium and vitamin D from dietary deficiencies results in a loss of bone density and increased risk of fractures. Older athletes are at high risk for osteoarthritis, a degenerative joint disorder that is unrelated loss of bone density.

A 77-year-old woman has been admitted to the geriatric medical unit of the hospital for the treatment of pneumonia. The nurse providing care for the client notes the presence of nasal calcitonin, vitamin D, and calcium chloride on the client's medication administration record. The nurse should conclude that this client likely has a history of: A. Scleroderma B. Osteoarthritis C. Rheumatoid arthritis D. Osteoporosis

D Common pharmacologic treatments for osteoporosis include nasal calcitonin, vitamin D supplements, and calcium supplements. This combination of drugs does not address the etiology or manifestations of scleroderma, osteoarthritis, or rheumatoid arthritis.

The condition that contributes to the pathology of all metabolic bone diseases is: A. Impaired vitamin D synthesis B. Osteosarcoma C. Infection D. Osteopenia

D Osteopenia is a condition that is common to all metabolic bone diseases. Metabolic diseases are noninfectious and are not neoplastic. Impaired vitamin D synthesis can cause osteopenia, but this phenomenon is not common to all metabolic bone diseases.

A 26-year-old woman has sought care for increasing pain at the back of her ankle and the bottom of her foot over the past 2 weeks. The client states that she is generally in good health, although she completed a course of antibiotics for a chlamydial infection 6 weeks earlier. This client's recent history suggests the possibility of: A. Systemic sclerosis B. Ankylosing spondylitis C. Osteoarthritis D. Reactive arthritis

D Reactive arthritis may be triggered by infections such as that caused by Chlamydia trachomatis. The Achilles tendon and plantar fascia are the most common sites of involvement, and this is nearly always accompanied by pain. Osteoarthritis, systemic sclerosis, and ankylosing spondylitis are not suggested by this specific chain of events.