Chapter 34: Assessment and Management of Clients with Inflammatory Rheumatic Disorders

33. A client who was just diagnosed with scleroderma will be undergoing tests to assess for systemic involvement. Which system should the nurse prioritize in assessment? A. Hepatic B. Gastrointestinal C. Genitourinary D. Neurologic

B Assessments of the hepatic, genitourinary, and neurologic systems are not central priorities.

36. A nurse is assessing a client with rheumatoid arthritis. The client expresses the intent to pursue complementary and alternative medicine (CAM) therapies. Which fact should underlie the nurse's response to the client? A. New evidence shows CAM to be as effective as medical treatment. B. CAM therapies negate many of the benefits of medications. C. CAM therapies typically do more harm than good. D. Most CAM therapies lack sufficient evidence to support them.

D

13. The nurse is preparing to care for a client who has scleroderma. The nurse refers to resources that describe CREST syndrome. Which condition is a component of CREST syndrome? A. Raynaud phenomenon B. Thyroid dysfunction C. Esophageal varices D. Osteopenia

ANS: A Rationale: CREST is a mnemonic to remember the signs and symptoms that clients typically exhibit with scleroderma. "C" stands for calcinosis (calcium deposits in the tissues). The "R" in CREST stands for Raynaud phenomenon, "E "for esophageal dysmotility, "S" for sclerodactyly (scleroderma of the digits), and "T "for telangiectasia (capillary dilation that leads to vascular lesions). Thyroid dysfunction, esophageal varices, and osteopenia are not directly associated with scleroderma.

6. A client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This client has been diagnosed with which health problem? A. Rheumatoid arthritis (RA) B. Systemic lupus erythematosus (SLE) C. Osteoporosis D. Polymyositis

ANS: A Rationale: In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately form pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not involve pannus formation.

10. A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A. "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B. "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." C. "OA originates with an infection. RA is a result of your body's cells attacking one another." D. "OA is associated with impaired immune function; RA is a consequence of physical damage."

ANS: A Rationale: OA is a degenerative arthritis with a noninflammatory etiology, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints, with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. The diseases are not distinguished by the joints affected and neither has an infectious etiology.

17. A nurse is working with a client with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the client is experiencing adverse effects of this drug? A. "I have this ringing in my ears that just won't go away." B. "I feel so foggy in the mornings and it takes me so long to wake up." C. "When I eat a meal that's high in fat, I get really nauseous." D. "I seem to have lost my appetite, which is unusual for me."

ANS: A Rationale: Tinnitus is associated with salicylate therapy. Salicylates do not normally cause drowsiness, intolerance of high-fat meals, or anorexia

4. A clinic nurse is caring for a client with suspected gout. While describing the pathophysiology of gout to the client, what should the nurse explain? A. Autoimmune processes in the joints B. Chronic metabolic acidosis C. Increased uric acid levels D. Unstable serum calcium levels

ANS: C Rationale: Gout is caused by hyperuricemia (increased serum uric acid). Gout is not categorized as an autoimmune disease and it does not result from metabolic acidosis or unstable serum calcium levels.

18. A client has been admitted to a medical unit with a diagnosis of polymyalgia rheumatica (PMR). The nurse should be aware of which aspects of PMR? Select all that apply. A. PMR has an association with the genetic marker HLA-DR4. B. Immunoglobulin deposits occur in PMR. C. PMR is considered to be a "wear-and-tear" disease. D. Foods high in purines exacerbate the biochemical processes that occur in PMR. E. PMR occurs predominately in Caucasians

ANS: A, B, E Rationale: The underlying mechanism involved with polymyalgia rheumatica is unknown. This disease occurs predominately in Caucasians and often in first-degree relatives.

31. A client with rheumatoid arthritis comes to the clinic reporting pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize? A. Take OTC calcium supplements consistently. B. Restrict consumption of foods high in purines. C. Ensure fluid intake of at least 4 L per day. D. Restrict weight-bearing on right foot

ANS: B Rationale: Although severe dietary restriction is not necessary, the nurse should encourage the client to restrict consumption of foods high in purines, especially organ meats. Calcium supplementation is not necessary and activity should be maintained as tolerated. Increased fluid intake is beneficial, but it is not necessary for the client to consume more than 4 L daily

25. A client has just been diagnosed with a spondyloarthropathy. Which nursing intervention should the nurse prioritize? A. Referral for assistive devices B. Teaching about symptom management C. Referral to classes to stop smoking D. Setting up an exercise program

ANS: B Rationale: Major nursing interventions in the spondyloarthropathies are related to symptom management and maintenance of optimal functioning. This is a priority over the use of assistive devices, smoking cessation, and exercise programs, though these topics may be of importance for some clients.

22. A nurse is caring for a client who is suspected of having giant cell arteritis (GCA). Which laboratory tests are most useful in diagnosing this rheumatic disorder? Select all that apply. A. Erythrocyte count B. Erythrocyte sedimentation rate C. Creatinine clearance D. C-reactive protein E. D-dimer

ANS: B, D Rationale: Simultaneous elevation in the erythrocyte sedimentation rate and C-reactive protein has a sensitivity of 98.6% and a specificity of 75.7% in making the diagnosis of GCA when coupled with clinical findings. Erythrocyte counts, creatinine clearance, and D-dimer are not diagnostically useful

15. A client with rheumatic disease has developed a gastrointestinal (GI) bleed. The nurse caring for the client should further assess for medications that typically exacerbate this condition. Which medication applies? A. Corticosteroids B. Immunomodulators C. Antimalarials D. Salicylate therapy

ANS: D Rationale: GI bleeding is an adverse effect that is associated with salicylates. Corticosteroids, antimalarials, and immunomodulators do not normally have this adverse effect.

A nurse is planning patient education for a patient being discharged home with a diagnosis of rheumatoid arthritis. The patient has been prescribed antimalarials for treatment, so the nurse knows to teach the patient to self-monitor for what adverse effect? A) Tinnitus B) Visual changes C) Stomatitis D) Hirsutism

B ANS: B Rationale: Antimalarials may cause visual changes; regular ophthalmologic examinations are necessary.

A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? A) Petechiae B) Erythematous rash C) Jaundice D) Skin sloughing

B Rationale: An acute cutaneous lesion consisting of an erythematous (butterfly-shaped) rash across the bridge of the nose and cheeks occurs in SLE. Petechiae are pinpoint skin hemorrhages, which are not a clinical manifestation of SLE. Clients with SLE do not typically experience jaundice or skin sloughing

A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid arthritis (RA). On what aspect of the patients health should the nurse focus most closely during the visit? A) The patients understanding of rheumatoid arthritis B) The patients risk for cardiopulmonary complications C) The patients social support system D) The patients functional status

D

A patients rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary care provider has added prednisone to the patients drug regimen. What principle will guide this aspect of the patients treatment? A) The patient will need daily blood testing for the duration of treatment. B) The patient must stop all other drugs 72 hours before starting prednisone. C) The drug should be used at the highest dose the patient can tolerate. D) The drug should be used for as short a time as possible.

D Rationale: Corticosteroids are used for shortest duration and at lowest dose possible to minimize adverse effects. Daily blood work is not necessary and the client does not need to stop other drugs prior to using corticosteroids.

A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient expresses angerand irritation when her call bell isnt answered immediately. What would be the most appropriate response? A) You seem like youre feeling angry. Is that something that we could talk about? B) Try to remember that stress can make your symptoms worse. C) Would you like to talk about the problem with the nursing supervisor? D) I can see youre angry. Ill come back when youve calmed down.

A

A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the patient appears to have lost some of her ability to function since her last office visit. Which of the following is the most appropriate action? A) Arrange a family meeting in order to explore assisted living options. B) Refer the patient to a support group. C) Arrange for the patient to be assessed in her home environment. D) Refer the patient to social work.

C Rationale: Assessment in the client's home setting can often reveal more meaningful data than an assessment in the health care setting. There is no indication that assisted living is a pressing need or that the client would benefit from social work or a support group.

5. A nurse is planning the care of a client who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. Which nursing diagnosis is most likely to apply to this client's care needs? A. Ineffective role performance related to pain B. Risk for impaired skin integrity related to myalgia C. Risk for infection related to tissue alterations D. Unilateral neglect related to neuropathic pain

ANS: A Rationale: Typically, clients with fibromyalgia have endured their symptoms for a long period of time. The neuropathic pain accompanying fibromyalgia can often impair a client's ability to perform normal roles and functions. Skin integrity is unaffected, and the disease has no associated infection risk. Activity limitations may result in neglect, but not of a unilateral nature.

8. A client has a diagnosis of rheumatoid arthritis, and the primary provider has now prescribed cyclophosphamide. The nurse's subsequent assessments should address which potential adverse effect? A. Bone marrow suppression B. Acute confusion C. Sedation D. Malignant hyperthermia

ANS: A Rationale: When administering immunosuppressives such as cyclophosphamide, the nurse should be alert to manifestations of bone marrow suppression and infection. Confusion and sedation are atypical adverse effects. Malignant hyperthermia is a surgical complication and not a possible adverse effect.

23. A client with a history of arthritis is being discharged to home after right wrist surgery, and the nurse reviews nonopioid pain relief measures. Which intervention(s) would best address the needs of this client? Select all that apply. A. Paraffin bath B. Nonsteroidal anti-inflammatory drugs (NSAIDs) C. Rolling walker D. Antiepileptic medications E. Splint or brace

ANS: A, B, E Rationale: Heat application helps relieve pain, stiffness, and muscle spasms. Paraffin baths (dips), which offer concentrated heat, are helpful to clients with wrist and small-joint involvement. Useful medications to control inflammation include NSAIDs (nonsteroidal anti-inflammatory drugs) and salicylates. Devices such as braces and splints ease pain by limiting movement.

28. A client with polymyositis is experiencing challenges with activities of daily living as a result of proximal muscle weakness. What is the most appropriate nursing action? A. Initiate a program of passive range of motion exercises B. Facilitate referrals to occupational and physical therapy C. Administer skeletal muscle relaxants as prescribed D. Encourage a progressive program of weight-bearing exercise

ANS: B Rationale: Clients with polymyositis may have symptoms similar to those of other inflammatory diseases. However, proximal muscle weakness is characteristic, making activities such as hair combing, reaching overhead, and using stairs difficult. Therefore, use of assistive devices may be recommended, and referral to occupational or physical therapy may be warranted. The muscle weakness is a product of the disease process, not lack of exercise. Skeletal muscle relaxants are not used in the treatment of polymyositis.

37. A nurse is providing care for a client who has just been diagnosed with early-stage rheumatoid arthritis (RA). The nurse should anticipate the administration of which medication? A. Hydromorphone B. Methotrexate C. Allopurinol D. Prednisone

ANS: B Rationale: Once the diagnosis of RA is made, treatment should begin with either a nonbiologic or biologic disease-modifying antirheumatic drug (DMARD). Recommended treatment guidelines include beginning with the nonbiologic DMARDs (methotrexate, leflunomide, sulfasalazine) or hydroxychloroquine within 3 months of disease onset. Allopurinol is used to treat gout. Opioids are not indicated in early RA. Prednisone is used in unremitting RA.

A nurse is providing care for a patient who has a rheumatic disorder. The nurses comprehensive assessment includes the patients mood, behavior, LOC, and neurologic status. What is this patients most likely diagnosis? A) Osteoarthritis (OA) B) Systemic lupus erythematosus (SLE) C) Rheumatoid arthritis (RA) D) Gout

ANS: B Rationale: SLE has a high degree of neurologic involvement and can result in central nervous system changes. The client and family members are asked about any behavioral changes, including manifestations of neurosis or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central nervous system manifestations. OA, RA, and gout lack this dimension.

1. A client with a documented history of allergies presents to the clinic. The client reports being frustrated by chronic nasal congestion, anosmia (inability to smell), and inability to concentrate. The nurse should identify which nursing diagnosis? A. Deficient knowledge of self-care practices related to allergies B. Ineffective individual coping with chronicity of condition C. Acute confusion related to cognitive effects of allergic rhinitis D. Disturbed body image related to sequelae of allergic rhinitis

ANS: B Rationale: The most appropriate nursing diagnosis is Ineffective Individual Coping with Chronicity of Condition. This nursing diagnosis is all encompassing of the subjective and objective data. Altered body image and acute confusion are not evidenced by the data. The client's condition is not necessary attributable to a knowledge defici

20. A nurse is educating a client with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make? A. Ensuring adequate rest B. Limiting exposure to sunlight C. Limiting intake of alcohol D. Smoking cessation

ANS: C Rationale: Alcohol and red meat can precipitate an acute exacerbation of gout. Each of the other listed actions is consistent with good health, but none directly addresses the factors that exacerbate gout.

11. A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement? A. "I'll make sure I get enough exposure to sunlight to keep up my vitamin D levels." B. "I'll try to be as physically active as possible between flare-ups." C. "I'll make sure to monitor my body temperature on a regular basis." D. "I'll stop taking my steroids when I get relief from my symptoms."

ANS: C Rationale: Fever can signal an exacerbation and should be reported to the health care provider. 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. As well, these drugs should not be independently adjusted by the client.

7. A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A. Cool joints with decreased range of motion B. Signs of systemic infection C. Joint stiffness lasting longer than 1 hour, especially in the morning D. Visible atrophy of the knee and shoulder joints

ANS: C Rationale: In addition to joint pain and swelling, another classic sign of RA is joint stiffness lasting longer than 1 hour, especially in the morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the disease. Joints are often warm rather than cool.

2. A 68-year-old client with a history of rheumatic disease has persistent swelling, no stiffness, and full range of motion to his left knee after an injury sustained several months ago. X-rays reveal no fracture of the extremity. Which factor is the most likely cause of the client's continued swelling? A. Degradation of cartilage B. Aging C. An inflammation process D. Reinjury not seen on x-ray results

ANS: C Rationale: Inflammation is a complex physiologic process mediated by the immune system that occurs in response to harmful stimuli such as damaged cells. Inflammation is meant to protect the body from insult by removing the triggering antigen or event. But sometimes the immune system deviates from a normal response. Instead of a resolution of swelling after the triggering event has subsided, a proliferation of newly formed synovial tissue infiltrated with inflammatory cells (pannus) occurs. Degradation in rheumatic diseases causes inflammation, bone stiffening, and cartilage failure

A patient with SLE asks the nurse why she has to come to the office so often for check-ups. What would be the nurses best response? A) Taking care of you in the best way involves seeing you face to face. B) Taking care of you in the best way involves making sure you are taking your medication the way it is ordered. C) Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working. D) Taking care of you in the best way involves drawing blood work every month.

ANS: C Rationale: The goals of treatment include preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease-related disabilities, and preventing complications from therapy. Management of SLE involves regular monitoring to assess disease process and therapeutic effectiveness.

29. A nurse is creating a teaching plan for a client who has a recent diagnosis of scleroderma. Which topics should the nurse address during health education? Select all that apply. A. Surgical treatment options B. Weight loss C. Management of Raynaud-type symptoms D. Exercise E. Skin care

ANS: C, D, E Rationale: Client teaching for the client with scleroderma focuses on management of Raynaud phenomenon, moderate exercise to prevent joint contractures, and meticulous skin care. Surgical treatment options do not exist, and weight loss is not a central concern.

19. A nurse is providing care for a client who has a recent diagnosis of giant cell arteritis (GCA). Which aspect of physical assessment should the nurse prioritize? A. Subtle signs of bleeding disorders B. The metatarsal joints and phalangeal joints C. Thoracic pain that is exacerbated by activity D. Headaches and jaw pain

ANS: D Rationale: Assessment of the client with GCA focuses on musculoskeletal tenderness, weakness, and decreased function. Careful attention should be directed toward assessing the head (for changes in vision, headaches, and jaw claudication). There is not a particular clinical focus on the potential for bleeding, hand and foot pain, or thoracic pain

9. A clinic nurse is caring for a client newly diagnosed with fibromyalgia. When developing a care plan for this client, which nursing diagnosis should the nurse prioritize? A. Impaired urinary elimination related to neuropathy B. Altered nutrition related to impaired absorption C. Disturbed sleep pattern related to central nervous system stimulation D. Fatigue related to pain

ANS: D Rationale: Fibromyalgia is characterized by fatigue, generalized muscle aching, and stiffness. Impaired urinary elimination is not a common manifestation of the disease. Altered nutrition and disturbed sleep pattern are potential nursing diagnoses, but are not the priority.

30. A 40-year-old woman was diagnosed with Raynaud phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The client also states that many of her skin surfaces are "stiff, like the skin is being stretched from all directions." The nurse should recognize the need for medical referral for the assessment of what health problem? A. Giant cell arteritis (GCA) B. Fibromyalgia (FM) C. Rheumatoid arthritis (RA) D. Scleroderma

ANS: D Rationale: Scleroderma starts insidiously with Raynaud phenomenon and swelling in the hands. Later, the skin and the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. This progression of symptoms is inconsistent with GCA, FM, or RA

27. A client is diagnosed with giant cell arteritis (GCA) and is placed on corticosteroids. A concern for this client is that the client will stop taking the medication as soon as the client starts to feel better. The nurse must emphasize the need for continued adherence to the prescribed medication so that the client can avoid which complication? A. Venous thromboembolism B. Osteoporosis C. Degenerative joint disease D. Blindness

ANS: D Rationale: The nurse must emphasize to the client the need for continued adherence to the prescribed medication regimen to avoid complications of giant cell arteritis, such as blindness. Venous thromboembolism, osteoporosis, and degenerative joint disease are not among the most common complications for GCA.

14. Allopurinol has been prescribed for a client receiving treatment for gout. The nurse caring for this client knows to assess the client for bone marrow suppression, which may be manifested by what diagnostic finding? A. Hyperuricemia B. Increased erythrocyte sedimentation rate C. Elevated serum creatinine D. Decreased platelets

ANS: D Rationale: Thrombocytopenia occurs in bone marrow suppression. Hyperuricemia occurs in gout, but is not caused by bone marrow suppression. Increased erythrocyte sedimentation rate may occur from inflammation associated with gout, but is not related to bone marrow suppression. An elevated serum creatinine level may indicate renal damage, but this is not associated with the use of allopurinol.

A nurses plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals? A) Maximize range of motion while minimizing exertion B) Increase joint size and strength C) Limit energy output in order to preserve strength for healing D) Preserve and increase range of motion while limiting joint stress

D