Chapter 64: Arthritis and Connective Tissue Diseases (Practice)

4. The nurse should teach the patient with ankylosing spondylitis the importance of a. regularly exercising and maintaining proper posture. b. avoiding extremes in environmental temperatures. c. maintaining patient's usual physical activity during flares. d. applying hot and cool compresses for relief of local symptoms.

A

7. Teach the patient with fibromyalgia the importance of limiting intake of which foods (select all that apply)? a. Sugar b. Alcohol c. Caffeine d. Red meat e. Root vegetables

A, B, C

40. Which action will the nurse include in the plan of care for a 40-year-old with newly diagnosed ankylosing spondylitis? a. Advise the patient to sleep on the back with a flat pillow. b. Emphasize that application of heat may worsen symptoms. c. Schedule annual laboratory assessment for the HLA-B27 antigen. d. Assist patient to choose physical activities that allow the spine to flex.

ANS: A Because ankylosing spondylitis results in flexion deformity of the spine, postures that extend the spine (such as sleeping on the back and with a flat pillow) are recommended. HLA-B27 antigen levels are used for initial diagnosis, but are not needed annually. To counteract the development of flexion deformities, the patient should choose activities that extend the spine, such as swimming. Heat application is used to decrease localized pain. DIF: Cognitive Level: Understand (comprehension) REF: 1537 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

44. A 28-year-old with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider? a. Crackles are heard in both lung bases. b. Red, scaly patches are noted on the arms. c. Hemoglobin level is 11.1g/dL and hematocrit is 35%. d. Patient reports continued back pain after a week of etanercept therapy.

ANS: A Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for a change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve symptoms. DIF: Cognitive Level: Apply (application) REF: 1529 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

18. The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding a. relief of joint pain. b. increased urine output. c. elevated serum uric acid. d. increased white blood cells (WBC).

ANS: A Colchicine produces pain relief in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day would increase urine output but would not indicate the effectiveness of colchicine. Elevated uric acid levels would result in increased symptoms. The WBC count might decrease with decreased inflammation, but would not increase. DIF: Cognitive Level: Understand (comprehension) REF: 1533 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

1. Which finding will the nurse expect when assessing a 58-year-old patient who has osteoarthritis (OA) of the knee? a. Discomfort with joint movement b. Heberdens and Bouchards nodes c. Redness and swelling of the knee joint d. Stiffness that increases with movement

ANS: A Initial symptoms of OA include pain with joint movement. Heberdens nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA). Stiffness in OA is worse right after the patient rests and decreases with joint movement. DIF: Cognitive Level: Understand (comprehension) REF: 1518 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

33. Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? a. Blurred vision b. Joint tenderness c. Abdominal cramping d. Elevated blood pressure

ANS: A Plaquenil can cause retinopathy. The medication should be stopped. The other findings are not related to the medication although they will also be reported. DIF: Cognitive Level: Apply (application) REF: 1522 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

11. The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a. a warm bath followed by a short rest. b. a short routine of isometric exercises. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

ANS: A Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased. DIF: Cognitive Level: Apply (application) REF: 1531 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. A 37-year-old patient with 2 school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that home life is very stressful. Which response by the nurse is most appropriate? a. Tell me more about situations that are causing you stress. b. You need to see a family therapist for some help with stress. c. Your family should understand the impact of your rheumatoid arthritis. d. Perhaps it would be helpful for your family to be involved in a support group.

ANS: A The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment. DIF: Cognitive Level: Apply (application) REF: 1530 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

36. A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? a. The blood pressure is 86/50 mm Hg. b. The white blood cell count is 11,500/L. c. The patient is taking ibuprofen (Motrin). d. The patient says the knee pain is severe.

ANS: A The low blood pressure suggests that the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should also be reported to the health care provider, but it does not indicate any immediately life-threatening problems. DIF: Cognitive Level: Apply (application) REF: 1535 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

37. A 63-year-old patient hospitalized with polymyositis has joint pain, an erythematosus facial rash, eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is a. risk for aspiration related to dysphagia. b. disturbed visual perception related to swelling. c. acute pain related to generalized inflammation. d. risk for impaired skin integrity related to scratching.

ANS: A The patients vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other nursing diagnoses also are appropriate but are not as high a priority as the maintenance of the patients airway. DIF: Cognitive Level: Apply (application) REF: 1545 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

1. During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)? a. Sleep disturbances b. Multiple tender points c. Cardiac palpitations and dizziness d. Multijoint pain with inflammation and swelling e. Widespread bilateral, burning musculoskeletal pain

ANS: A, B, E These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia. DIF: Cognitive Level: Understand (comprehension) REF: 1547 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. Which action will the nurse include in the plan of care for a 33-year-old patient with a new diagnosis of rheumatoid arthritis? a. Instruct the patient to purchase a soft mattress. b. Suggest that the patient take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.

ANS: B Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress. When stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve the flexibility and strength of the affected joints, and the patients overall endurance. DIF: Cognitive Level: Apply (application) REF: 1531 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

27. The nurse determines that additional instruction is needed when a patient diagnosed with scleroderma says which of the following? a. Paraffin baths can be used to help my hands. b. I should lie down for an hour after each meal. c. Lotions will help if I rub them in for a long time. d. I should perform range-of-motion exercises daily.

ANS: B Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective. DIF: Cognitive Level: Apply (application) REF: 1544 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

8. Which information will the nurse include when preparing teaching materials for patients with exacerbations of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Application of cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

ANS: B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises. DIF: Cognitive Level: Apply (application) REF: 1531 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

38. A 46-year-old male patient with dermatomyositis is receiving long-term prednisone (Deltasone) therapy. Which assessment finding by the nurse is most important to report to the health care provider? a. The blood glucose is 112 mg/dL. b. The patient has painful hematuria. c. Acne is noted on the patients face. d. The patient has an increased appetite.

ANS: B Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection. DIF: Cognitive Level: Apply (application) REF: 1522 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

29. Which assessment information obtained by the nurse indicates that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone (Deltasone)? a. The patient has joint pain and stiffness. b. The patients blood glucose is 165 mg/dL. c. The patient has experienced a recent 5-pound weight loss. d. The patients erythrocyte sedimentation rate (ESR) has increased.

ANS: B Corticosteroids have the potential to cause diabetes mellitus. The finding of an elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication. DIF: Cognitive Level: Apply (application) REF: 1522 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

2. Which assessment finding about a patient who has been using naproxen (Naprosyn) for 6 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider? a. The patient has gained 3 pounds. b. The patient has dark-colored stools. c. The patients pain has become more severe. d. The patient is using capsaicin cream (Zostrix).

ANS: B Dark-colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by the naproxen. The information about the patients ongoing pain and weight gain also will be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate. DIF: Cognitive Level: Apply (application) REF: 1521 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. Which information will the nurse include when teaching a 38-year-old male patient with newly diagnosed ankylosing spondylitis (AS) about the management of the condition? a. Exercise by taking long walks. b. Do daily deep-breathing exercises. c. Sleep on the side with hips flexed. d. Take frequent naps during the day.

ANS: B Deep-breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps. DIF: Cognitive Level: Apply (application) REF: 1537 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

41. After the nurse has taught a 28-year-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? a. I am going to join a soccer team to get more exercise. b. I will need to stop drinking so much coffee and soda. c. I will call the doctor every time my symptoms get worse. d. I should avoid using over-the-counter medications for pain.

ANS: B Dietitians frequently suggest that patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently, rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management. DIF: Cognitive Level: Apply (application) REF: 1548 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

26. A 40-year-old African American patient has scleroderma manifested by CREST (calcinosis, Raynauds phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep environment warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

ANS: B Keeping the room warm will decrease the incidence of Raynauds phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose levels or to assist the patient to the bathroom every 2 hours. DIF: Cognitive Level: Apply (application) REF: 1544 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

25. The health care provider has prescribed the following collaborative interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Naproxen (Aleve) 200 mg BID. d. Famotidine (Pepcid) 20 mg daily.

ANS: B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient. DIF: Cognitive Level: Apply (application) REF: 1540 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor a. blood glucose. b. blood pressure. c. erythrocyte count. d. lymphocyte count.

ANS: B Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cell (RBC) count, or lymphocytes. DIF: Cognitive Level: Apply (application) REF: 1534 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

34. A 31-year-old woman is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis. Which information from the patients health history is important for the nurse to report to the health care provider about the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

ANS: B Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy. DIF: Cognitive Level: Apply (application) REF: 1529 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

45. Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma? a. Monitor for difficulty in breathing. b. Document the patients oral intake. c. Check finger strength and movement. d. Apply capsaicin (Zostrix) cream to hands.

ANS: B Monitoring and documenting patients oral intake is included in UAP education and scope of practice. Assessments for changes in physical status and administration of medications require more education and scope of practice, and should be done by licensed nurses. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

3. After the nurse has finished teaching a 68-year-old patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. I can take glucosamine to help decrease my knee pain. b. I will take 1 g of acetaminophen (Tylenol) every 4 hours. c. I will take a shower in the morning to help relieve stiffness. d. I can use a cane to decrease the pressure and pain in my hip.

ANS: B No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management. DIF: Cognitive Level: Apply (application) REF: 1520 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

21. Which statement by a patient with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurses teaching about the condition? a. I will exercise even if I am tired. b. I will use sunscreen when I am outside. c. I should take birth control pills to keep from getting pregnant. d. I should avoid aspirin or nonsteroidal antiinflammatory drugs.

ANS: B Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE. DIF: Cognitive Level: Apply (application) REF: 1542 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

32. Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

ANS: B The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process. DIF: Cognitive Level: Apply (application) REF: 1538 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is most appropriate? a. Teach the patient about adverse effects of the RA medications. b. Suggest that the patient use over-the-counter (OTC) artificial tears. c. Reassure the patient that dry eyes are a common problem with RA. d. Ask the health care provider about discontinuing methotrexate (Rheumatrex) .

ANS: B The patients dry eyes are consistent with Sjgrens syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself. DIF: Cognitive Level: Apply (application) REF: 1546 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

42. Which information will the nurse include when teaching a patient with newly diagnosed chronic fatigue syndrome about self-management? a. Avoid use of over-the-counter antihistamines or decongestants. b. A low-residue, low-fiber diet will reduce any abdominal distention. c. A gradual increase in your daily exercise may help decrease fatigue. d. Chronic fatigue syndrome usually progresses as patients become older.

ANS: C A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with chronic fatigue syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. Chronic fatigue syndrome usually does not progress. DIF: Cognitive Level: Apply (application) REF: 1524 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

12. Anakinra (Kineret) is prescribed for a 49-year-old patient who has rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. avoiding concurrently taking aspirin. b. symptoms of gastrointestinal (GI) bleeding. c. self-administration of subcutaneous injections. d. taking the medication with at least 8 oz of fluid.

ANS: C Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued. DIF: Cognitive Level: Apply (application) REF: 1529 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

31. A patient with an acute attack of gout in the right great toe has a new prescription for probenecid (Benemid). Which information about the patients home routine indicates a need for teaching regarding gout management? a. The patient sleeps about 8 to 10 hours every night. b. The patient usually eats beef once or twice a week. c. The patient takes one aspirin a day to prevent angina. d. The patient usually drinks about 3 quarts water daily.

ANS: C Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patients sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout. DIF: Cognitive Level: Apply (application) REF: 1534 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

24. The nurse is planning care for a patient with hypertension and gout who has a red and painful right great toe. Which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the right foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach patient to avoid use of acetaminophen (Tylenol).

ANS: C Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain relief. DIF: Cognitive Level: Understand (comprehension) REF: 1534 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

35. Which laboratory data is important to communicate to the health care provider for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis? a. The blood glucose is 90 mg/dL. b. The rheumatoid factor is positive. c. The white blood cell (WBC) count is 1500/L. d. The erythrocyte sedimentation rate is elevated.

ANS: C Bone marrow suppression is a possible side effect of methotrexate, and the patients low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in rheumatoid arthritis. The blood glucose is normal. DIF: Cognitive Level: Apply (application) REF: 1529 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

9. Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose test b. Liver function tests c. C-reactive protein level d. Serum electrolyte levels

ANS: C C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels will also be monitored to check for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids. DIF: Cognitive Level: Apply (application) REF: 1527 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

4. The nurse will anticipate the need to teach a 57-year-old patient who has osteoarthritis (OA) about which medication? a. Adalimumab (Humira) b. Prednisone (Deltasone) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

ANS: C Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA. DIF: Cognitive Level: Apply (application) REF: 1520 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

28. When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate (Rheumatrex). The patient tells the nurse, My arthritis isnt that bad yet. The side effects of methotrexate are worse than the arthritis. The most appropriate response by the nurse is a. You have the right to refuse to take the methotrexate. b. Methotrexate is less expensive than some of the newer drugs. c. It is important to start methotrexate early to decrease the extent of joint damage. d. Methotrexate is effective and has fewer side effects than some of the other drugs.

ANS: C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible. DIF: Cognitive Level: Apply (application) REF: 1529 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. A 19-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. had several knee injuries as a teenager. b. recently returned from South America. c. is sexually active with multiple partners. d. has a parent who has rheumatoid arthritis.

ANS: C Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis. DIF: Cognitive Level: Understand (comprehension) REF: 1535 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

39. Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)? a. A 38-year-old man who plays on a summer softball team b. A 56-year-old man who is a member of a construction crew c. A 56-year-old woman who works on an automotive assembly line d. A 49-year-old woman who is newly diagnosed with diabetes mellitus

ANS: C OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve nonrepetitive work and thus would not be as risky. DIF: Cognitive Level: Apply (application) REF: 1524 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

17. A 29-year-old patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with a. anakinra (Kineret). b. etanercept (Enbrel). c. doxycycline (Vibramycin). d. methotrexate (Rheumatrex).

ANS: C Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis. DIF: Cognitive Level: Apply (application) REF: 1537 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

5. A patient with rheumatoid arthritis being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules.

ANS: C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence. DIF: Cognitive Level: Apply (application) REF: 1527 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

ANS: C The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE. DIF: Cognitive Level: Apply (application) REF: 1540 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

16. The nurse notices a circular lesion with a red border and clear center on the arm of an 18-year-old summer camp counselor who is in the camp clinic complaining of chills and muscle aches. Which action should the nurse takenext? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.

ANS: C The patients clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patients symptoms do not suggest cardiac or abdominal problems or lack of immunization. DIF: Cognitive Level: Apply (application) REF: 1534 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

20. A 71-year-old patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of a. sertraline (Zoloft). b. famotidine (Pepcid). c. oxycodone (Roxicodone). d. hydrochlorothiazide (HydroDIURIL).

ANS: D Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer. DIF: Cognitive Level: Apply (application) REF: 1532 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

43. After the nurse assesses a 78-year-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management, which information is most important to report to the health care provider? a. Knee crepitation is noted with normal knee range of motion. b. Patient reports embarrassment about having Heberdens nodes. c. Patients knee pain while golfing has increased over the last year. d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

ANS: D Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will also be reported to the health care provider but is consistent with the patients diagnosis of osteoarthritis and will not require an immediate change in the patients treatment plan. DIF: Cognitive Level: Apply (application) REF: 1532 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests that they a. stand rather than sit when performing household and yard chores. b. strengthen small hand muscles by wringing sponges or washcloths. c. protect the knee joints by sleeping with a small pillow under the knees. d. avoid activities that require repetitive use of the same muscles and joints.

ANS: D Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion (ROM). DIF: Cognitive Level: Apply (application) REF: 1530 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

46. When reviewing the chart shown in the accompanying figure for a new patient with rheumatoid arthritis, the nurse reads that the patient has swan neck deformities. Which deformity will the nurse expect to observe when assessing the patient? a. A b. B c. C d. D

ANS: D Swan neck deformity involves distal interphalangeal joint hyperflexion and proximal interphalangeal joint hyperextension of the hands. The other deformities are also associated with rheumatoid arthritis: ulnar drift, boutonniere deformity, and hallux vagus. DIF: Cognitive Level: Understand (comprehension) REF: 1527 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE

30. The home health nurse is doing a follow-up visit to a 41-year-old patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins daily. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head.

ANS: D The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective. DIF: Cognitive Level: Apply (application) REF: 1531 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

22. A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, I never leave my house because I hate the way I look. An appropriate nursing diagnosis for the patient is a. activity intolerance related to fatigue and inactivity. b. impaired social interaction related to lack of social skills. c. impaired skin integrity related to itching and skin sloughing. d. social isolation related to embarrassment about the effects of SLE.

ANS: D The patients statement about not going anywhere because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient. DIF: Cognitive Level: Apply (application) REF: 1542 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

1. In assessing the joints of a patient with osteoarthritis, the nurse understands that Bouchard's nodes a. are often red, swollen, and tender. b. indicate osteophyte formation at the PIP joints. c. are the result of pannus formation at the DIP joints. d. occur from deterioration of cartilage by proteolytic enzymes.

B

3. When administering medications to the patient with chronic gout, the nurse would recognize which drug is used as a treatment for this disease? a. Colchicine b. Febuxostat c. Sulfasalazine d. Cyclosporine

B

2. A patient with rheumatoid arthritis is experiencing articular involvement. The nurse recognizes these characteristic changes include (select all that apply) a. bamboo-shaped fingers. b. metatarsal head dislocation in feet. c. noninflammatory pain in large joints. d. asymmetric involvement of small joints. e. morning stiffness lasting 60 minutes or more.

B,E

6. In teaching a patient with Sjögren's syndrome about drug therapy for this disorder, the nurse includes instruction on use of which drug? a. Pregabalin (Lyrica) b. Etanercept (Enbrel) c. Cyclosporine (Restasis) d. Cyclobenzaprine (Flexeril)

C

5. In teaching a patient with SLE about the disorder, the nurse knows the pathophysiology of SLE includes a. circulating immune complexes formed from IgG autoantibodies reacting with IgG. b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer. c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles. d. the production of a variety of autoantibodies directed against components of the cell nucleus.

D