Ch 34: Inflammatory Rheumatic Disorders PrepU

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 with rheumatoid arthritis wants to participate in water aerobics classes for arthritis at the community center. Which statement will the nurse respond to this client?

"Be sure to wear nonslip footwear for safety." Appropriate programs of exercise have been shown to decrease pain and improve function in rheumatoid arthritis. Pool exercises provide a buoyant medium for performance of dynamic or aerobic exercise and the water supports movement while warm water provides muscle relaxation. The client should be reminded to wear nonslip footwear for safety and comfort. Range of motion exercises should not be done if the joints are inflamed. Dynamic exercise is not the best for unstable or misaligned joints. Blood pressure should be checked before engaging in isometric exercises.

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.

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.

The nurse is caring for a client with palindromic rheumatism. The nurse knows that this type of rheumatism can lead to which diagnosis?

Rheumatoid arthritis Palindromic rheumatism is an uncommon variety of recurring and acute arthritis and periarthritis that in some may progress to rheumatoid arthritis (RA) but is characterized by symptom-free periods of days to months. Because of this, the nurse should plan care that would be similar to the client with RA. The symptoms of palindromic rheumatism are not similar to those of scleroderma, fibromyalgia, or systemic lupus erythematosus.

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 gout has been advised to lose weight. The client informs the nurse of 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.

An older adult with rheumatoid arthritis says exercise was not effective. Which response will the nurse make to learn the reason for the failure of this treatment approach?

"What types of exercise were you doing?" In an older adult with rheumatoid arthritis, exercise programs may not be instituted or may be ineffective because the client expects results too quickly or fails to appreciate the effectiveness of a program of exercise. Strength training is encouraged in the older adult with chronic diseases. The other questions will not help the nurse understand what type of exercise was used and what it was not effective for the client.

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.

The nurse is assessing a client with rheumatoid arthritis. The nurse knows that prolonged inflammation can cause compression of nerves. Which symptoms would accompany this level of involvement?

Paresthesia of both hands The rheumatoid arthritis inflammatory process has been implicated in other disease processes. The nervous system is affected as synovial inflammation can compress adjacent nerves, causing neuropathies and paresthesias. Limited motion in the wrists and restricted movement in the tendons is caused by a breakdown of collagen and pannus formation which destroys cartilage and erodes the bone. This causes a loss of articular surfaces and joint motion and tendon and ligament elasticity and contractility is lost. Rheumatoid arthritis does not cause crepitus with movement.

A client with systemic lupus erythematosus (SLE) is prescribed hydroxychloroquine. Which teaching will the nurse include for this client?

Smoking cessation An antimalarial medication, hydroxychloroquine, is effective for managing cutaneous, musculoskeletal, and mild systemic features of SLE. However, smoking inhibits the effectiveness of hydroxychloroquine. Because of this, teaching on smoking cessation would be a priority. Teaching about exercise would not be a priority because of the medication. A high-protein diet is not indicated as treatment for SLE. Vitamin D supplements would be applicable if the client is taking corticosteroids.

The nurse is gathering objective data for a client at the clinic reporting 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.

The nurse is providing education for a client with a new diagnosis of rheumatoid arthritis (RA). Which statement will the nurse include in the discussion with the client? Select all that apply.

Swelling of the joints will occur, causing pain You can expect warmth in your joints Redness can occur in the skin at the joints A symptom of RA will be joint pain on both sides. The initial clinical manifestations of RA include symmetric joint pain and morning joint stiffness lasting longer than 1 hour. Symmetric joint pain, swelling, warmth, erythema, and lack of function are classic symptoms. A rash is not a symptom of RA.

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.

A client is taking ibuprofen for the treatment of osteoarthritis. What education will the nurse give the client about the medication?

Take the medication with food to avoid stomach upset. Ibuprofen is a nonsteroidal anti-inflammatory drug. The nurse should advise the patient to take NSAIDs with food to avoid stomach upset. Ibuprofen is available over the counter, but it still has side effects. Aspirin is known to cause ringing in the ears, not NSAIDs.

The nurse is constructing a teaching plan for the client newly diagnosed with scleroderma. What should the nurse include in the teaching plan?

Protect the hands and feet from cold. Raynaud's phenomenon is associated with scleroderma. Client teaching must include strategies for protecting the feet and hands.

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.

As part of the assessment process for a client suspected of having gout, the nurse evaluated the client's serum uric acid levels. Select the value that is considered above the saturation point for crystal formation.

6.8 mg/dL (0.40 mmol/L) Hyperuricemia, a serum uric acid concentration above 6.8 mg/dL (0.40 mol/L) can cause urate crystal deposition which can lead to gout.

A client is experiencing painful joints and changes in the lungs, heart, and kidneys. For which condition will the nurse schedule this client for diagnostic tests?

Autoimmune disorders A hallmark of inflammatory rheumatic diseases is autoimmunity, where the body mistakenly recognizes its own tissue as a foreign antigen. Although focused in the joints, inflammation and autoimmunity also involve other areas. The blood vessels (vasculitis and arteritis), lungs, heart, and kidneys may be affected by the autoimmunity and inflammation. It is unlikely that the client's array of symptoms is being caused by heart disease, vascular diseases, or metabolic disorders.

The nurse is teaching a client about the characteristics of osteoarthritis. The nurse determines the client teaching was successful when the client states that which of the following may occur with osteoarthritis?

Clients may develop Heberden nodes Heberden nodes are a characteristic finding of osteoarthritis. Swan neck deformity, boutonniere deformity, and ulnar deviation are characteristic of rheumatoid arthritis.

A client is suspected of having CREST syndrome and is seeking medical attention. Which criterion is among those used to diagnose this client?

Esophageal dysmobility There is no one conclusive diagnostic test used to diagnose scleroderma. Generally, the patient is diagnosed with the CREST type of scleroderma if they have four of the five symptoms in the syndrome, which include esophageal dysmobility, calcinosis (calcium deposits in the tissues), Raynaud's phenomenon, sclerodactyly (scleroderma of the digits), and telangiectasia (capillary dilation that forms a vascular lesion). Voice volume, liver enzymes, and white blood cell count are not findings that are used to diagnose CREST syndrome.

The nurse is teaching a client with osteoarthritis about the disease. What is the most important client focus for disease management?

strategies for remaining active The goals of osteoarthritis disease management are to decrease pain and stiffness and improve joint mobility. Strategies for remaining active are the most important client focus. The detection of complications, disease-modifying antirheumatic drugs management, and prevention of joint deformity are considerations, but not the most important priorities for the client.

The nurse is performing a health history with a new client with fibromyalgia. What will 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.

The nurse is teaching a newly diagnosed client about systemic lupus erythematosus(SLE). What statement by the client indicates the teaching was successful?

"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 side effect of bone marrow depression may occur with which medication used to treat gout?

Allopurinol A client taking allopurinol needs to be monitored for the side effects of bone marrow depression, vomiting, and abdominal pain.

A client with rheumatoid arthritis is prescribed a tumor necrosis factor (TNF)-alpha inhibitor. What medication 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.

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.

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

Prone It is best for the client with rheumatoid arthritis to lie prone several times daily to prevent hip flexion contracture. Semi-Fowler's position, side-lying with pillows, and supine with pillows are positions that have hip flexion.

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 planning teaching for a client with gout. Which topics will the nurse include in the teaching? Select all that apply.

Weight loss Decreasing alcohol intake Avoiding purine-rich foods Management between the attacks of gout include lifestyle changes to include weight loss, decreasing alcohol intake, and avoiding purine-rich foods. Exercise does not need to be limited and water does not need to be restricted.

The nurse is gathering a health history for a client with osteoarthritis. What clinical manifestation will the nurse expect to find?

early morning stiffness Osteoarthritis is characterized by early morning stiffness that decreases with activity. Large joints are usually involved with osteoarthritis. Joint pain is a constant with osteoarthritis. Clients with rheumatoid arthritis have subcutaneous nodules.

A client with rheumatoid arthritis expresses not feeling the need to take medication any longer since being in remission without symptoms. What is the best response by the nurse?

"It is important that you continue to take your medication to avoid an acute exacerbation." Even with remission, most people must continue taking prescribed medications to avoid another acute exacerbation. The client should be encouraged to maintain the therapeutic regimen in order to avoid an exacerbation and prolong the period of remission as long as possible. The client should notify the physician if considering discontinuation of the medication. The nurse is not at liberty to allow the client to discontinue medication use. Stating that discontinuing the medication will cause the client to become ill does not provide an adequate explanation to the client.

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).

The nurse is reviewing medications prescribed for a client with rheumatoid arthritis. Which medications will the nurse expect to be prescribed for this client? Select all that apply.

Aspirin • ibuprofen • methotrexate Medications are used with the rheumatic diseases to manage symptoms, to control inflammation, and, in some instances, to modify the disease. Medications used include the salicylates, NSAIDs, and DMARDs. Opioid and anticoagulants are not identified as being used to treat rheumatoid arthritis.

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.

The nurse is preparing to educate a client with rheumatoid arthritis on long-term effects of prednisone therapy. Which topic will the nurse include in the teaching?

Eat a lower calorie diet to manage weight gain. Common side effects of prednisone include weight gain and increased hunger. The nurse should educate the client on eating a well-balanced diet with a decreased calorie intake. Weight gain is common so it does not need to be reported immediately. A client should not decrease number of meals and should not fast as this can cause malnutrition and decreased energy to deal with chronic disease.

A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening?

Lung sounds are diminished in the apical area 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.

The nurse is preparing teaching for a client with rheumatoid arthritis (RA). Which information will the nurse include in these instructions? Select all that apply.

Medication therapy • nutritious eating plan • actions to cope with stress • nonpharmacological pain management techniques Client education is an essential aspect in nursing care of the client with RA to enable the client to maintain as much independence as possible, to take medications accurately and safely, and to use adaptive devices correctly. Teaching should include name, dose, side effects, frequency, and schedule for all medications; a dietary plan that focuses on weight management while maximizing nutrients for tissue building and repair;ways to cope with stress; and pain management techniques. A client with rheumatoid arthritis can lead a fulfilling life independently as long as they are supported with the appropriate equipment and skills to live in their home.

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 Methotrexate is a DMARD that reduces the amount of joint damage and slows the damage to other tissues as well. Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID). Methylprednisolone is a steroid to reduce pain and inflammation and slow joint destruction. Mercaptopurine azathioprine is a cytotoxic drug.

A client is experiencing symptoms of giant cell arteritis (GCA). Which action will be taken to definitively diagnose this condition?

Obtain the results of a temporal artery biopsy. The diagnosis of GCA can be difficult because of the lack of specificity of tests. However, in the case of GCA, biopsy of the temporal artery is the definitive diagnostic tool. The C-reactive protein can be used to diagnose GCA if other clinical findings are present. The response to corticosteroids may be considered as diagnostic for GCA and polymyalgia rheumatica. A markedly high erythrocyte sedimentation rate is a screening test but is not definitive for GCA.

During a home visit, the nurse notes that a client with polymyositis has difficulty combing the hair and putting on socks and shoes. Which referrals will the nurse recommend for this client? Select all that apply. •

Physical therapy • Occupational therapy Clients with polymyositis may have symptoms similar to those of other inflammatory diseases. However, proximal muscle weakness is characteristic, making activities such as combing the hair, reaching overhead, and using stairs difficult. Therefore, the use of assistive devices may be recommended, and referral to physical therapy or occupational therapy may be warranted. There is no need for a referral to hospice, pastoral care, or social services.

Which intervention should the nurse implement to manage pain for the client with rheumatoid arthritis? Select all that apply.

Support joint with splint and pillows • provide diversional activities • Provide opportunities for the client to verbalize their feelings To manage pain, the nurse maintains normal alignment of extremities as much as possible by supporting the joints with splints and pillows. Diversional activities distract the client's focus from the pain. Providing opportunities for the client to verbalize feelings facilitates coping with pain. Assistive devices for self-feeding help the client meet nutritional needs independently. Assisting the client to develop a sleep routine promotes rest and minimizes fatigue.

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.

The nurse is assessing a client with a history of ankylosing spondylitis. What will the nurse most commonly assess?

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 associated with systemic lupus erythematosus. Ankylosing spondylitis does not affect urine output.

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.

The nurse is performing a health history with a new client in the clinic. What is the most common reason for a client 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 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 osteoarthritis expresses concerns that the disease will prevent the ability to complete daily 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 oneself during daily activities. Telling the client to do 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 oneself and take frequent rests rather than doing all chores at once.

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.

The nurse is caring for a client with scleroderma. Which findings will the nurse expect during the physical assessment? Select all that apply.

Dry Skin • Rigid Extremities • Expressionless Face • Absence of facial wrinkles Scleroderma is a rare autoimmune disease affecting the connective tissue of the skin. The skin and subcutaneous tissues become increasingly hard and rigid due to excess collagen and cannot be pinched up from the underlying structures. The skin is dry because sweat secretion over the involved region is suppressed. The extremities stiffen and lose mobility. The face appears masklike, immobile, and expressionless. Wrinkles and lines are obliterated. A discoid rash is associated with systemic lupus erythematosus.

A nurse assesses a client in the health care provider'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.

A client is prescribed a disease-modifying antirheumatic drug that is successful in the treatment of rheumatoid arthritis but has side effects, including retinal eye changes. What medication will the nurse anticipate educating the client about?

Hydroxychloroquine The DMARD hydroxychloroquine is associated with visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. The nurse should emphasize the need for ophthalmologic examinations every 6-12 months. Azathioprine, diclofenac, and cyclophosphamide do not have visual changes as a side effect.

A client with rheumatoid arthritis wants to try nonpharmacologic approaches to control the pain and stiffness. Which approaches will the nurse suggest that might improve the client's comfort and mobility? Select all that apply.

Imagery • Massage • Self-hypnosis • Chiropractic adjustments Physical and occupational therapy programs and interventions are beneficial in improving physical activity and maintaining range of motion. Such interventions may include stretching exercises, massage, and chiropractic manipulation. Other strategies for decreasing pain include imagery and self-hypnosis. Golf is not identified as improving range of motion or improving discomfort.

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.

A diet plan is developed for a client with gouty arthritis. What should the nurse advise the client to limit the 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.

A client is seen in the office for reports of joint pain, swelling, and a low-grade fever. What blood studies does the nurse know are consistent with a positive diagnosis of rheumatoid arthritis (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 caring for a client with palindromic rheumatism. The nurse knows that this type of rheumatism can lead to which diagnosis?

Rheumatoid arthritis Palindromic rheumatism is an uncommon variety of recurring and acute arthritis and periarthritis that in some may progress to rheumatoid arthritis (RA) but is characterized by symptom-free periods of days to months. Because of this, the nurse should plan care that would be similar to the client with RA. The symptoms of palindromic rheumatism are not similar to those of scleroderma, fibromyalgia, or systemic lupus erythematosus.

A client has been living with rheumatoid arthritis (RA) for several years. Which diagnostic test will the nurse prepare the client for to determine the progression of the disease?

X-ray Plain x-ray is the most common radiographic study used to track disease progression as it is inexpensive, reliable, and reproducible. MRI may be used to detect erosions not visible on x-ray or ultrasound. CT scan is not routinely used to track the progression of RA. Ultrasound might be used to establish a baseline for joint evaluation however is not used to track progression of the condition.

The nurse is caring for a client with polymyositis. Which type of medication will the nurse explain to this client?

Coricosteroids The goal is to control inflammation and prevent long-term damage to muscles, joints, and internal organs. Corticosteroid therapy is the mainstay of medical management of the client with polymyositis. Antibiotics, anticoagulants, and nonsteroidal anti-inflammatory drugs are not used to treat polymyositis.

A client is admitted with an acute attack of gout. What interventions are essential for this client? Select all that apply.

Dietary consult • Probenecid • Corticosteroid therapy • pain medication • serum uric acid concentration Steroids may be used in clients who have not responded to other therapies. They have been shown to decrease inflammation and pain in attacks of gout. Probenecid will assist in the excretion of uric acid, the causative agent. Serum uric acid concentrations will guide therapy and treatment. A dietary consult can wait until the client the acute, painful period is over but will be a necessary nursing intervention for a client experiencing gout.

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 client is admitted with an acute attack of gout. What interventions are essential for this client? Select all that apply.

Dietary Consult Probenecid Corticosteroid therapy Pain medication Serum Uric acid concentration Steroids may be used in clients who have not responded to other therapies. They have been shown to decrease inflammation and pain in attacks of gout. Probenecid will assist in the excretion of uric acid, the causative agent. Serum uric acid concentrations will guide therapy and treatment. A dietary consult can wait until the client the acute, painful period is over but will be a necessary nursing intervention for a client experiencing gout.

A client with rheumatoid arthritis reports disrupted sleep because of pain and stiffness. Which recommendations will the nurse make to help the client achieve restful sleep? Select all that apply.

Use relaxation exercises. • Establish a set time to sleep every night • Avoid caffeine before bedtime • Create a quiet sleep environment Clients need restful sleep so that they can cope with pain, minimize physical fatigue, and deal with the changes related to having a chronic disease. In clients with acute disease, sleep time is frequently reduced and fragmented by prolonged awakenings. Recommendations to improve sleep include using relaxation exercises, establishing a set time to sleep, avoiding caffeine before bedtime, and creating a quiet sleep environment. Pain medications should be taken closer to sleep time so that they can work effectively for someone experiecing pain and stiffness due to rheumatoid disease.

A health care provider orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis?

An above normal anti-deoxyribonucleic acid (DNA) Test Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE.

The result of which diagnostic study is decreased in the client diagnosed with rheumatoid arthritis?

Red blood cell count Clients diagnosed with rheumatic diseases have a decreased red blood cell count. ESR is increased in inflammatory connective tissue disease. Uric acid is increased in gout. Increased creatinine may indicate renal damage in SLE, scleroderma, and polyarteritis.

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.

A nurse is assessing a client with possible osteoarthritis. What is the most significant risk factor for primary osteoarthritis?

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.

Which term refers to fixation or immobility of a joint?

Ankylosis Ankylosis is the fixation or immobility of a joint. It may result from a disease process or from 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 is caring for a client with systemic lupus erythematosus (SLE). Which interventions will the nurse incorporate into this client's plan of care? Select all that apply. •

Antipyretic medications for fever • Providing high fiber diet for diarrhea • Monitoring for rash to the skin The disease process of SLE involves chronic states where symptoms are minimal or absent and acute flares where symptoms and lab results are elevated. Symptoms most often include fever, joint pain, and a discoid rash. SLE less commonly affects the gastrointestinal system and the liver. Because of this jaundice and diarrhea are not findings associated with SLE.

A client with rheumatoid arthritis tells the nurse about experiencing mild tinnitus, gastric intolerance, and rectal bleeding. What medication does the nurse suspect is causing these side effects?

Aspirin Salicylates like aspirin may have side effects such as tinnitus, gastric intolerance and bleeding. While celecoxib, methotrexate, and hydroxychloroquine have GI upset effects, the tinnitus is unique to aspirin.

A client asks the nurse how their rheumatoid arthritis is diagnosed. The nurse knows that which finding from diagnostic tests can be used to diagnose rheumatoid arthritis?

Boney erosions on x-ray The American College of Rheumatology and the European League Against Rheumatism have established criteria for classifying RA. These criteria are based on a point system where a total score of 6 or greater is required for the diagnosis of RA. Clients diagnosed with RA who are excluded from these diagnostic criteria include those with bony erosions on X-ray. RA is not diagnosed by CT scans, MRIs, or arteriograms, however CT scans and MRIs can be used to detect bone erosions and inflammatory changes of rheaumatoid arthritis.

A client with a history of peptic ulcer disease is diagnosed with rheumatoid arthritis. What medication will the nurse anticipate will be prescribed to produce an anti-inflammatory effect and protect the stomach lining?

Celecoxib The cyclooxygenase-2 inhibitors, such as celecoxib, have been shown to inhibit inflammatory processes but do not inhibit the protective prostaglandin synthesis in the gastrointestinal (GI) tract. Therefore, patients who are at increased risk for gastrointestinal complications, especially GI bleeding, have been managed effectively with celecoxib. Ibuprofen, methotrexate, and sulfasalazine may cause GI irritation.

The nurse is teaching a client about the characteristics of osteoarthritis. How will the nurse determine the client teaching was successful?

Clients may develop Heberden nodes. Heberden nodes are a characteristic finding of osteoarthritis. Swan neck deformity, boutonniere deformity, and ulnar deviation are characteristic of rheumatoid arthritis.

The nurse is caring for a client with a new onset of gout. What medication does the nurse anticipate will be ordered by the health care provider?

Colchicine The treatment of gout involves managing the acute inflammatory stage, preventing flare-ups, and controlling hyperuricemia. Colchicine, along with indomethacin, ibuprofen, or a corticosteroid, is prescribed to relieve an acute attack of gout. Probenecid and anturane increase the urinary excretion of uric acid, and allopurinol breaks down purines before uric acid is formed.

A client is being placed on a purine-restricted diet. What foods will the nurse include in the client's diet plan?

Dairy Products Purines are chemical compounds found in high concentrations in certain foods, particularly shellfish, organ meats, and some alcoholic beverages (e.g., beer, distilled liquors). Purines are implicated in gout. Another reason that clients with gout are advised to avoid alcohol is that alcohol of any kind may increase the free fatty acid concentrations that can exacerbate gout.

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.

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What 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.

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 methyl salicylate may be used for pain management.

A client cringes in pain when the nurse places the stethoscope over the upper back to assess breath sounds. On which condition will the nurse focus when assessing this client?

Fibromyalgia The amplified pain experienced by clients with fibromyalgia is thought to be neurogenic in origin. The central nervous system's ascending and descending pathways that regulate and moderate pain processing function abnormally, causing amplification of pain signals. Stimulation that may not normally elicit pain, such as touching with a stethoscope, may cause pain. The pain of liver disease is typically felt in the right upper abdomen. The pain of gallbladder disease is referred to the upper right shoulder blade. Ankylosing spondylitis does not cause pain of the upper back.

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.

A client who has been diagnosed with osteoarthritis asks if he or she will eventually begin to notice deformities in the hands and fingers as the condition progresses. Which concept should the nurse include in the 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 client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse not say 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.

A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. What instruction should the nurse give to the client to minimize injury?

Install safety devices in the home Most accidents occur in the home, and safety devices such as hand rails are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or lifting objects. Protective devices aren't usually necessary when the client exercises.

A client has a serum study that is positive for the rheumatoid factor. What will the nurse tell the client about the significance of this test result?

It is suggestive of rheumatoid arthritis. Rheumatoid factor is present in about 70% to 80% of patients with rheumatoid arthritis, but its presence alone is not diagnostic of rheumatoid arthritis, and its absence does not rule out the diagnosis. The antinuclear antibody (ANA) test is used to diagnose Sjögren's syndrome and systemic lupus erythematosus.

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 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.

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.

The nurse is educating a client on signs and symptoms of fibromyalgia. Which assessment technique would cause pain that indicates fibromyalgia?

Pinch the Achilles tendon. Since fibromyalgia is a diffuse syndrome, standard diagnostic testing is often not useful except to rule out other conditions that may be causing the pain. One study reported that pain upon pinching the Achilles tendon using 4 kg of pressure for 4 seconds is useful in recognizing fibromyalgia. A positive response to this screening item needs to be followed by a comprehensive examination for confirmation of a diagnosis. Applying pressure to the thumb, striking the patella with a reflex hammer, or inflating the blood pressure cuff an extra 20 mm Hg are not techniques used to screen for fibromyalgia.

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 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.

The client asks the nurse about types of exercise that do not stress the joints. What exercise will the nurse include in the teaching plan?

Tai chi Tai chi is low impact, so this is the best exercise for low joint impact. Jogging, weight lifting, and running on a treadmill are high-impact, jarring types of exercise.

The client with an inflamed knee scheduled to have an arthrocentesis asks the nurse what the synovial fluid will look like. What is the best response by the nurse?

The fluid will be 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.

A client is recovering from an attack of gout. What will the nurse include in the client teaching?

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 will not reduce purine levels, reduce inflammation, or increase uric acid levels.

A nurse is managing the care of a client with osteoarthritis. What is the appropriate treatment strategy the nurse will teach the about for osteoarthritis?

administration of nonsteroidal anti-inflammatory drugs (NSAIDs) 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.

The nurse is reviewing the medication administration record of the client. Which medication 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.

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 client with a history of gout experiences an attack every 2 to 3 months despite losing weight and stopping all alcohol intake. Which question will the nurse ask when assessing this client?

"Are you taking the medication as prescribed?" Medication adherence is critical but poor among clients prescribed uric lowering therapies for gout. Between acute episodes, the client feels well and may abandon medications and preventive behaviors, which may result in an acute attack. Asking about medication adherence is the appropriate. Exercise, fat-soluble vitamins, and rest periods will not increase the risk of having an attack of gout.

A nurse is assigned to a client with polymyositis. Which expected outcome in the care plan relates to a potential problem associated with polymyositis?

"Client will exhibit no signs or symptoms of aspiration." An expected outcome of no signs or symptoms of aspiration relates to symmetrical muscle weakness — a potential problem associated with polymyositis that may lead to speaking and swallowing problems. A client with a potential swallowing problem is at risk for inadequate nutrition and shouldn't be placed on a calorie-restricted diet; an expected outcome focusing on maintaining weight would be more appropriate than an outcome based on losing weight. Polymyositis doesn't affect bowel or bladder function or mental status; it isn't necessary to develop outcomes based on these parameters.

A client presents with an edematous and red left great toe and reports the same symptoms occured 2 months ago. Which questions will the nurse ask to determine if the client is experiencing gout? Select all that apply.

"Have you had any recent surgeries?" • "Have you had any changes in your oral intake?" • "What time of the day does the pain occur?" • "Do you consume alcoholic beverages?" • "How long did the previous episode last?" Acute arthritis is the most common early clinical manifestation of gout. The attack may be precipitated by stress from a recent surgery. The abrupt onset of an attack often occurs at night that awakens the client with severe pain, redness, swelling, and warmth of the affected joint. The attack may be precipitated by alcohol intake. Previous attacks tend to subside spontaneously over 3 to 10 days without treatment which is followed by a symptom-free period until the next attack, which may not come for months or years.

The nurse instructs a client with polymyositis rheumatica (PMR) about prescribed corticosteroids. Which statement regarding corticosteroid is correct?

"I will take the medication until my health care provider tells me to stop." A management concern of clients with PMR is taking the medication as prescribed. Oftentimes clients will take the medication until symptoms improve and then will discontinue the medication. The decision to discontinue the medication should be based on clinical and laboratory findings and the length of the prescription. The dose should not be altered and doses should not be skipped if gastric distress occurs.

A client with fibromyalgia asks why physical therapy has been prescribed. Which response will the nurse make?

"It will help with the overall deconditioning that has occurred." Treatment of fibromyalgia consists of attention to the specific symptoms that the client is experiencing. An individualized program of exercise is used to decrease muscle weakness and discomfort and improve the general deconditioning that occurs in clients with the condition. Physical therapy is not used to take the health problem off of the client's mind. The health care provider is treating the client's symptoms and has determined that physical therapy would be helpful. There are a variety of medications available to treat the symptoms of fibromyalgia.

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 suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine positivity 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 health care provider, stating that SLE is a serious systemic disorder, and asking the client to express feelings about the potential diagnosis do not answer the client's question

A client with rheumatoid arthritis comes to the clinic for a second dose of etanercept. The dose prescribed is 25 mg subcutaneously. The medication is available in 50 mg per milliliter. How many milliliters will the nurse administer to the client? Record your answer using one decimal place.

0.5 25 mg/50 mg per mL = 0.5 mL.

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.

The nurse is caring for a client with hypertension and scleroderma. Which medication will the nurse expect to be prescribed for this client?

Angiotensin-converting enzyme inhibitors Treatment of scleroderma is mainly symptomatic and supportive. No medication regimen is effective in modifying the disease process in scleroderma, but various medications are used to treat organ system involvement. The use of angiotensin-converting enzyme inhibitors when there is kidney involvement has led to a substantial decrease in mortality from hypertensive kidney disease. Diuretics, vasodilators, and beta blockers are not used to treat hypertension caused by scleroderma.

The nurse is caring for a client with systemic lupus erythematosus (SLE). Which interventions will the nurse incorporate into this client's plan of care? Select all that apply.

Antipyretic medications for fever • providing analgesics for joint pain • monitoring for rash on skin The disease process of SLE involves chronic states where symptoms are minimal or absent and acute flares where symptoms and lab results are elevated. Symptoms most often include fever, joint pain, and a discoid rash. SLE less commonly affects the gastrointestinal system and the liver. Because of this jaundice and diarrhea are not findings associated with SLE.

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

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

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.

The nurse is planning care in the home for a client with rheumatoid arthritis. What instruction(s) should the nurse include in the plan of care? Select all that apply.

Collaborate with occupational therapists for specialized equipment. Identify the exercise regimen planned by physical therapist. Provide nursing assistance for ADLs. Ensure the home environment is safe. The nurse should collaborate with occupational therapists for specialized equipment, identify the exercise regimen planned by physical therapist, provide nursing assistance for ADLs, and ensure the home environment is safe. The nurse should teach the nursing assistant to allow extra time in the morning, not the evening, for hygiene or other procedures.

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.

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.

Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)?

Disease-modifying antirheumatic drugs (DMARDs) Once a diagnosis of RA has been made, treatment should begin with DMARDs. NSAIDs are used for pain and inflammation relief but must be used with caution in long-term chronic diseases due to the possibility of gastric ulcers. TNF blockers interfere with the action of tumor necrosis factor (TNF). Oral glucocorticoids, such as prednisone and prednisolone, are indicated for patients with generalized symptoms.

The nurse is caring for a client who has been diagnosed with a "rheumatic disease." What nursing diagnoses will most likely apply to this client's care? Select all that apply.

Fatigue • Pain • Alteration of self-concept Clients with rheumatic diseases, which typically involve joints and muscles, experience problems with mobility, fatigue, and pain. Because of the limitations of the disease, clients often have an altered self-image and self-concept. Fluid and electrolyte imbalances are not typically associated with these types of diseases.

A client comes to the clinic and reports pain in the right great toe which is worse at night. Assessment reveals tophi. What does the nurse suspect?

Gouty arthritis Gout results from the inability to metabolize purines. This condition is most commonly seen in men and usually affects the legs, feet, and knees. Osteoarthritis is caused by degeneration of the joints. Rheumatoid arthritis is a systemic disorder more common in women of childbearing age. Reactive arthritis is seen with infections and is most common in young adult males.

A client diagnosed with degenerative joint disease of the fingers reports now having bumps on the fingers that do not hurt. The nurse observes bony nodules on the distal interphalangeal joints. What type of "bumps" does the nurse understand these are?

Heberden nodes DJD affects the hands; the fingers frequently develop painless bony nodules on the dorsolateral surface of the interphalangeal joints. Heberden nodes are bony enlargement of the distal interphalangeal joints. Bouchard nodes are bony enlargement of the proximal interphalangeal joints. Rheumatoid nodules are associated with rheumatoid arthritis. Tophi occur with gout and elevated uric acid levels.

A client is newly diagnosed with rheumatoid arthritis. For which medications will the nurse prepare teaching for this client? Select all that apply.

Ibuprofen Prednisone Methotrexate Once the diagnosis of RA is made, treatment should begin with either a nonbiologic or biologic disease-modifying antirheumatic drugs (DMARD). The goal of using DMARD therapy is preventing inflammation and joint damage. Recommended treatment guidelines include beginning with the nonbiologic DMARD methotrexate as the preferred agent. Ibuprofen may be prescribed as an analgesic however must be used with caution because of the risk of gastric ulcer. Corticosteroids are recommended as a 'bridge' in the early treatment but are not recommended for long term therapy due to side effects. Aspirin and acetaminophen are not identified as medications used to treat the symptoms of RA

The nurse is assessing a client with decreased dexterity of the hands related to rheumatoid arthritis. The nurse knows that which process causes joint deformities?

Inflammation In clients with chronic inflammation, the immune response can deviate from normal. Instead of resolution of swelling and joint pain once the triggering event has subsided, pannus, or proliferation of newly formed synovial tissue infiltrated with inflammatory cells, formation occurs. Destruction of the joint's cartilage and erosion of bone soon follow. Remission is a period when the symptoms of the condition are reduced or absent. Exacerbation is a period when the symptoms occur or increase. Autoimmunity causes tissue destruction which leads to pain.

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 has a history of osteoarthritis. Which signs and symptoms should the nurse expect to find on physical assessment?

Joint pain, crepitus, Heberden's nodes Clinical findings for osteoarthritis include joint pain, crepitus, Heberden's nodes (bony growths at the distal interphalangeal joints), Bouchard's nodes (growths involving the proximal interphalangeal joints), and enlarged joints. The joint pain occurs with movement and is relieved by rest. As the disease progresses, pain may also occur at rest. Bouchard's nodes involve the proximal interphalangeal joints. Hot, inflamed joints rarely occur in osteoarthritis. Tophi are deposits of sodium urate crystals that occur in chronic gout — not osteoarthritis. Swelling, joint pain, and tenderness on palpation occur with a sprain injury.

Which of the following maybe the first and only physical sign of symptomatic osteoarthritis (OA)?

Limited passive movement Limited passive movement can be the first and only physical sign of symptomatic OA. Physical assessment of the musculoskeletal system reveals joint enlargement, joint instability, and limb shortening.

The nurse is preparing teaching for a client with rheumatoid arthritis (RA). Which information will the nurse include in these instructions? Select all that apply.

Medication therapy • Nutritious eating plan • Actions to cope with stress • Nonpharmacologic pain management techniques Client education is an essential aspect in nursing care of the client with RA to enable the client to maintain as much independence as possible, to take medications accurately and safely, and to use adaptive devices correctly. Teaching should include name, dose, side effects, frequency, and schedule for all medications; a dietary plan that focuses on weight management while maximizing nutrients for tissue building and repair; ways to cope with stress; and pain management techniques. A client with rheumatoid arthritis can lead a fulfilling life independently as long as they are supported with the appropriate equipment and skills to live in their home.

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.

The nurse is caring for a client with ankylosing spondylitis (AS). Which medication will the nurse expect to be prescribed for this client?

Nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs are the first-line therapy for treating all spondyloarthropathies. Antibiotics and anticoagulants are not used to treat AS. Corticosteroid injections may be used for periodic flares; however, oral and long-term use of steroids is not recommended.

A client with kyphosis caused by ankylosing spondylitis (AS) asks if there are any procedures available to help with the spinal deformity and pain. Which procedure will the nurse prepare teaching for this client?

Osteotomy of the spine With advanced AS and subsequent debilitating kyphosis, an osteotomy of the spine can be done. Bracing, traction, and the use of a cervical collar are not identified as being used to help with the kyphosis caused by AS.

A client with systemic lupus erythematosus is prescribed belimumab. For which reason will the nurse question giving the client this medication?

Received a live vaccination a week ago Belimumab is a monoclonal antibody that specifically recognizes and binds to BLyS. BLyS acts to stimulate B cells to produce antibodies against the body's own nuclei, which is an integral part of the disease process in SLE. This action then halts the production of unnecessary antibodies and decreases disease activity in SLE. Live vaccines are contraindicated for 30 days before taking this medication. There is no reason to withhold giving the medication for a report of constipation, discoid rash on the face, or bilateral knee joint swelling.

A client with rheumatoid arthritis has infiltration of the lacrimal and salivary glands with lymphocytes as a result of the disease. What does the nurse understand that this clinical manifestation is?

Sicca Syndrome Sicca syndrome is a condition of dry eyes and dry mouth that can result from infiltration of the lacrimal and salivary glands with lymphocytes. Episcleritis is an inflammatory condition of the connective tissue between the sclera and conjunctiva. Glaucoma results from increased intraocular pressure, and cataracts are a clouding of the lens in the eye.

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.

The nurse is completing a health history with a client in a clinic. What assessment finding best correlates with a diagnosis of osteoarthritis?

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

A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse 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. The nodules are not reddened.

A client seeks medical attention for the development of red scaly lesions over the surface of both knees. Which question will the nurse ask to determine if the client is experiencing polymyositis?

"Have you had a change in the strength of your legs?" Polymyositis is classified as autoimmune because autoantibodies are present. The onset may be very slow and insidious, with symptoms gradually worsening over weeks to months. Proximal muscle weakness is typically the first symptom. Muscle weakness is usually symmetric and diffuse. Dermatomyositis, a related condition, is most commonly identified by an erythematous smooth or scaly lesion found over the joint surface, which often occurs prior to symptoms of weakness in 50% to 60% of clients. Because of this, the question about leg strength should be asked. Questions about medications, dry skin, and use of soap would not be questions that relate to the diagnosis of dematomyositis.

The nurse is preparing to assess a client experiencing symptoms of gout. Which findings indicate to the nurse that the client is experiencing gout syndrome? Select all that apply.

Tophi • Uric acid urinary calculi • Severe articular inflammation There are specific manifestations associated with gout syndrome. These manifestations include tophi, uric acid calculi, and severe articular inflammation. Lower extremity wounds and lack of hair over the lower extremities are not findings associated with gout syndrome.