Chapter 38: assessment and management of patients with rheumatic disorders

The nurse is teaching a client with osteoarthritis about the disease. What is the most important client focus for disease management? A.) detection of systemic complications B.) strategies for remaining active C.) disease-modifying antirheumatic drug therapy D.) prevention of joint deformity

Answer: B.) strategies for remaining active Rationale: 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 reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find? A.) Increased red blood cell count B.) Increased C4 complement C.) Elevated erythrocyte sedimentation rate D.) Increased albumin levels

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

A diet plan is developed for a client with gouty arthritis. What should the nurse advise the client to limit the intake of? A.) citrus fruits B.) green vegetables C.) organ meats D.) fresh fish

Answer: C.) organ meats Rationale: 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.

Which assessment suggests to the nurse that a client with systemic lupus erythematous is having renal involvement? A.) Chest pain B.) Decreased cognitive ability C.) Behavioral changes D.) Hypertension

Answer: D.) Hypertension Rationale: Hypertension is suggestive of renal damage in the client with systemic lupus erythematous.

The nurse is teaching a client about rheumatic disease. What statement best helps to explain autoimmunity? A.) "You have inherited your parent's immunity to the disease." B.) "Your symptoms are a result of your body attacking itself." C.) "You have antigens to the disease, but they do not prevent the disease." D.) "You are not immune to the disease causing the symptoms."

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

A client comes to the emergency department complaining of pain in the right leg. When obtaining the history, the nurse learns that the client has a history of obesity and hypertension. Based on this information the nurse anticipates the client having which musculoskeletal disorder? A.) Degenerative joint disease B.) Muscular dystrophy C.) Scoliosis D.) Paget's disease

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

Scleroderma typically starts with which type of organ involvement? A.) Skin B.) Lung C.) Brain D.) Kidney

Answer: A.) Skin Rationale: Scleroderma commonly begins with skin involvement. Mononuclear cells cluster on the skin and stimulate lymphokines to stimulate procollagen. Scleroderma does not commonly begin in the lung, brain, or kidney.

What intervention is a priority for a client diagnosed with osteoarthritis? A.) Physical therapy and exercise B.) Hydrotherapy C.) Colchicine D.) Allopurinol

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

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? A.) penicillamine B.) methotrexate C.) prednisone D.) colchicine

Answer: D.) colchicine Rationale: Colchicine is prescribed for the treatment of an acute attack of gout.

A nurse assesses a client in the health care provider's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)? A.) Facial erythema, pericarditis, pleuritis, fever, and weight loss B.) Photosensitivity, polyarthralgia, and painful mucous membrane ulcers C.) Weight gain, hypervigilance, hypothermia, and edema of the legs D.) Hypothermia, weight gain, lethargy, and edema of the arms

Answer: A.) Facial erythema, pericarditis, pleuritis, fever, and weight loss Rationale: 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 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? A.) If you have problems with a medication, you may stop it until your next physician visit. B.) Avoid sunlight and ultraviolet radiation. C.) Pace activities. D.) Maintain a well-balanced diet and increase fluid intake to raise energy levels and promote tissue healing.

Answer: A.) If you have problems with a medication, you may stop it until your next physician visit. Rationale: 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.

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? A.) Methotrexate (Rheumatrex) B.) Etanercept (Enbrel) C.) Methylprednisolone (Medrol) D.) Infliximab (Remicade)

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

A client has had several diagnostic tests to determine if he has systemic lupus erythematosus (SLE). What result is very specific indicator of this diagnosis? A.) Positive Anti-dsDNA antibody test B.) Positive Anti-Sm antibodies C.) Positive ANA titer D.) Elevated ESR

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

Which of the following disorders is characterized by an increased autoantibody production? A.) Systemic lupus erythematosus (SLE) B.) Scleroderma C.) Rheumatoid arthritis (RA) D.) Polymyalgia rheumatic

Answer: A.) Systemic lupus erythematosus (SLE) Rationale: 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 recovering from an attack of gout. What will the nurse include in the client teaching? A.) Weight loss will reduce purine levels. B.) Weight loss will reduce inflammation. C.) Weight loss will increase uric acid levels and reduce stress on joints. D.) Weight loss will reduce uric acid levels and reduce stress on joints.

Answer: D.) Weight loss will reduce uric acid levels and reduce stress on joints. Rationale: 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.

The nurse is completing a health history with a client in a clinic. What assessment finding best correlates with a diagnosis of osteoarthritis? A.) joint stiffness that increases with activity B.) erythema and edema over the affected joint C.) anorexia and weight loss D.) fever and malaise

Answer: A.) joint stiffness that increases with activity Rationale: 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.

Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues? A.) Rheumatoid arthritis B.) Systemic lupus erythematosus C.) Polymyalgia rheumatic D.) Scleroderma

Answer: D.) Scleroderma Rationale: 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 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? A.) Heberden nodes B.) jaw locking C.) widespread chronic pain D.) butterfly facial rash

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

A client with osteoarthritis expresses concerns that the disease will prevent the ability to complete daily chores. Which suggestion should the nurse offer? A.) "Do all your chores in the morning, when pain and stiffness are least pronounced." B.) "Do all your chores after performing morning exercises to loosen up." C.) "Pace yourself and rest frequently, especially after activities." D.) "Do all your chores in the evening, when pain and stiffness are least pronounced."

Answer: C.) "Pace yourself and rest frequently, especially after activities." Rationale: 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.

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. A.) 3.2 mg/dL (0.19mmol/L) B.) 4.0 mg/dL (0.24 mmol/L) C.) 5.4 mg/dL (0.32 mmol/L) D.) 6.8 mg/dL (0.40 mmol/L)

Answer: D.) 6.8 mg/dL (0.40 mmol/L) Rationale: 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.

Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage? A.) Subchondral bone B.) Pannus C.) Joint effusion D.) Tophi

Answer: D.) Tophi Rationale: 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.

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?

Answer: 50 Rationale: 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.

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? A.) "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B.) "OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints." C.) "OA affects joints on both sides of the body. RA is usually unilateral." D.) "OA is more common in women. RA is more common in men."

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

What is the priority intervention for a client who has been admitted repeatedly with attacks of gout? A.) Assess diet and activity at home B.) Place client on bed rest C.) Increase fluids D.) Insert a Foley catheter

Answer: A.) Assess diet and activity at home Rationale: 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 intervenes to assist the client with fibromyalgia to cope with which symptoms? A.) Chronic fatigue, generalized muscle aching, and stiffness B.) Pain, viral infection, and tremors C.) Diminished vision, chronic fatigue, and reduced appetite D.) Generalized muscle aching, mood swings, and loss of balance

Answer: A.) Chronic fatigue, generalized muscle aching, and stiffness Rationale: 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.

Osteoarthritis is known as a disease that A.) is the most common and frequently disabling of joint disorders. B.) affects young males. C.) requires early treatment because most of the damage seems to occur early in the course of the disease. D.) affects the cartilaginous joints of the spine and surrounding tissues.

Answer: A.) is the most common and frequently disabling of joint disorders. Rationale: 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.

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? A.) "My legs feel weak." B.) "My finger joints are oddly shaped." C.) "I have pain in my hands." D.) "I have trouble with my balance."

Answer: B.) "My finger joints are oddly shaped." Rationale: 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 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? A.) "You should discuss that matter with your health care provider." B.) "The diagnosis won't be based on the findings of a single test but by combining all data found." C.) "SLE is a very serious systemic disorder." D.) "Tell me more about your concerns about this potential diagnosis."

Answer: B.) "The diagnosis won't be based on the findings of a single test but by combining all data found." Rationale: 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.

Which is an appropriate nursing intervention in the care of the client with osteoarthritis? A.) Provide an analgesic after exercise B.) Encourage weight loss and an increase in aerobic activity C.) Assess for gastrointestinal complications associated with COX-2 inhibitors D.) Avoid the use of topical analgesics

Answer: B.) Encourage weight loss and an increase in aerobic activity Rationale: 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 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? A.) osteoarthritis B.) gouty arthritis C.) rheumatoid arthritis D.) reactive arthritis

Answer: B.) gouty arthritis Rationale: 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 nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan? A.) "Exposure to sunlight will help control skin rashes." B.) "There are no activity limitations between flare-ups." C.) "Monitor your body temperature." D.) "Corticosteroids may be stopped when symptoms are relieved."

Answer: C.) "Monitor your body temperature." Rationale: 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 is taking ibuprofen for the treatment of osteoarthritis. What education will the nurse give the client about the medication? A.) Take the medication on an empty stomach in order to increase effectiveness. B.) Since the medication is able to be obtained over the counter, it has few side effects. C.) Take the medication with food to avoid stomach upset. D.) Inform the health care provider if there is ringing in the ears.

Answer: C.) Take the medication with food to avoid stomach upset. Rationale: 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.

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included? A.) The time of day when exercise is performed isn't important. B.) Exercising in the evening before going to bed is beneficial. C.) Exercising immediately upon awakening allows the client to participate in activities when he has the greatest amount of energy. D.) 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.

Answer: D.) 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. Rationale: 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.