Ch 62 MS trauma and orthopedic surgery, ch 62 MS trauma and orthopedic surgery, Ch. 62 - Musculoskeletal Trauma & Orthopedic Surgery, Chapter 62: Musculoskeletal Trauma and Orthopedic Surgery, Chapter 64: Arthritis and Connective Tissue Diseases, Lew...

A 66-year-old man with type 2 diabetes mellitus and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask? "Did you have any hypoglycemic reactions?" "Have you noticed any bruising or bleeding?" "Have you had any dizzy spells when standing up?" "Do you have any numbness or tingling in your feet?"

"Have you noticed any bruising or bleeding?" Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both glucosamine and chondroitin may increase the risk of bleeding. Anticoagulant therapy is indicated for patients with atrial fibrillation to reduce the risk of a thromboembolism and a stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose levels, and hyperglycemia may occur. Peripheral neuropathy symptoms that can develop with prolonged hyperglycemia include numbness and tingling in the feet.

The nurse obtains a history from a 46-year-old woman with rheumatoid arthritis. It is most important for the nurse to follow up on which patient statement? "I perform range of motion exercises at least twice a day." "I use a heating pad for 20 minutes to reduce morning stiffness." "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

"I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)." Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which statement? "I should take the Naprosyn as prescribed to help control the pain." "I should try to stay standing all day to keep my joints from becoming stiff." "I can use a cane if I find it helpful in relieving the pressure on my back and hip." "A warm shower in the morning will help relieve the stiffness I have when I get up."

"I should try to stay standing all day to keep my joints from becoming stiff." It is important to maintain a balance between rest and activity to prevent overstressing the joints with OA. Naproxen (Naprosyn) may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.

A female patient's complex symptomatology over the past year has led to a diagnosis of systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? "I'll try my best to stay out of the sun this summer." "I know that I probably have a high chance of getting arthritis." "I'm hoping that surgery will be an option for me in the future." "I understand that I'm going to be vulnerable to getting infections."

"I'm hoping that surgery will be an option for me in the future." Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.

A 24-year-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? "Infertility can result from the medications used to control your disease." "Pregnancy will result in a temporary remission of your signs and symptoms." "Autoantibodies transferred to the baby during pregnancy will cause heart defects." "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth."

"Infertility can result from the medications used to control your disease." Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common following pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.

A 62-year-old woman diagnosed with fibromyalgia syndrome (FMS) reports difficulty sleeping at night. Which suggestion should the nurse give to the patient? "Drinking a glass of red wine 30 minutes before bedtime will reduce anxiety and help you fall asleep." "Evening primrose oil is an herbal supplement that can be used as a sleep aid and to relieve anxiety." "Melatonin is a hormone that is often used in supplements to improve sleep and ease fibromyalgia pain." "Diphenhydramine (Benadryl) is a nonprescription sleep aid that is effective and does not cause tolerance."

"Melatonin is a hormone that is often used in supplements to improve sleep and ease fibromyalgia pain." Melatonin is a hormone prepared as a supplement. Scientific evidence suggests that melatonin decreases sleep latency and may increase the duration of sleep. In addition, melatonin may decrease fatigue and pain in individuals with fibromyalgia. Alcohol should not be consumed 4 to 6 hours before bedtime. Evening primrose oil is an herbal product used for breast pain (oral form) and skin disorders (topical form). Long-term use of diphenhydramine for sleep causes tolerance.

The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern 2 × 6 cm right calf abrasion with sanguineous drainage Left leg externally rotated and shorter thatthe right leg Stooped posture with a shuffling gait and slow movements Mild pain and minimal swelling of the right ankle and foot

2 left leg Rationale: Manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

ANS: C Because fat embolism can occur with tibial fracture, the nurse's first action should be to check the patient's O2 saturation. The other actions are also appropriate but not as important at this time as obtaining the patient's O2 saturation.

44. Based on the information in the accompanying figure obtained for a patient in the emergency room, which action should the nurse take first? a. Administer the prescribed morphine 4 mg IV. b. Contact the operating room to schedule surgery. c. Check the patient's O2 saturation using pulse oximetry. d. Ask the patient the date of the last tetanus immunization.

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

ANS A The low blood pressure suggests 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 be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

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

ANS B Monitoring and documenting patient's 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 RNs

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

ANS B 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.

Which patient seen by the nurse in the outpatient clinic is most likely to need teaching about ways to reduce the risk for osteoarthritis (OA)? a. A 56-yr-old man who has a sedentary office job b. A 38-yr-old man who plays on a summer softball team c. A 38-yr-old woman who is newly diagnosed with diabetes d. A 56-yr-old woman who works on an automotive assembly line

ANS D OA is more likely to occur in women as a result of estrogen reduction at menopause and in persons whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a risk factor for OA. Sedentary work is not a risk factor for OA.

What finding should indicate to the nurse that colchicine has been effective for a patient with an acute attack of gout? a. Reduced joint pain b. Increased urine output c. Elevated serum uric acid d. Increased white blood cells

ANS: A Colchicine reduces joint pain in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day during acute gout would increase urine output but would not indicate the effectiveness of colchicine. Elevated serum uric acid would result in increased symptoms. The WBC count might decrease with decreased inflammation but would not increase.

A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Considering this treatment, which information should the nurse report to the health care provider? 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

3. What should the occupational health nurse advise a patient whose job involves many hours of typing? a. Obtain a keyboard pad to support the wrist. b. Do stretching exercises before starting work. c. Wrap the wrists with compression bandages every morning. d. Avoid using nonsteroidal antiinflammatory drugs (NSAIDS).

ANS: A Repetitive strain injuries caused by prolonged work at a keyboard can be prevented by using a pad to keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting work. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to decrease swelling.

14. A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? a. Check the patient's prescribed weight-bearing status. b. Use a mechanical lift to transfer the patient to the chair. c. Decrease the pain medication before getting the patient up. d. Have the unlicensed assistive personnel (UAP) transfer the patient.

ANS: A The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish the transfer.

Which action should the nurse include in the plan of care for a patient with newly diagnosed ankylosing spondylitis? a. Have the patient sleep on their back with a flat pillow. b. Discuss 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 involve spinal flexion.

ANS: A Because ankylosing spondylitis results in flexion deformity of the spine, postures that extend the spine (e.g., sleeping on the back and with a flat pillow) are recommended. HLA-B27 antigen is assessed for initial diagnosis but is 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.

A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding should the nurse report immediately to the health care provider? a. The patient has painful hematuria. b. Acne is noted on the patient's face. c. Fasting blood glucose is 112 mg/dL. d. The patient has an increased appetite

ANS: A 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

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

ANS: A Dietitians often suggest 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

Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis should the nurse identify as a likely 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. Other findings are not related to the medication although they will also be reported.

A 25-yr-old female patient with systemic lupus erythematosus (SLE) has a facial rash and alopecia. She tells the nurse, "I never leave my house because I hate the way I look." Which patient problem should the nurse plan to address? a. Social isolation b. Activity intolerance c. Impaired skin integrity d. Impaired social interaction

ANS: A The patient's statement about not going anywhere because of hating the way he or she looks expresses 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. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

During assessment of the patient with fibromyalgia, the nurse should 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 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.

42. After change-of-shift report, which patient should the nurse assess first? a. Patient with a repaired mandibular fracture who is reporting facial pain. b. Patient with repaired right femoral shaft fracture who reports tightness in the calf. c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity. d. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated.

ANS: B Calf swelling after a femoral shaft fracture suggests possible DVT or compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries but do not require immediate intervention.

A patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action should the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep the 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 Raynaud's 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 or to assist the patient to the bathroom every 2 hours.

5. A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. Which information will the nurse include in postoperative teaching? a. "You will not be able to serve a tennis ball again." b. "You will begin work with a physical therapist tomorrow." c. "Keep the shoulder immobilizer on for the first 4 days to minimize pain." d. "The surgeon will use the drop arm test to determine the success of surgery."

ANS: B Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion. The drop arm test is used to test for rotator cuff injury but not after surgery. The patient may be able to return to tennis after rehabilitation.

25. After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer prescribed PRN O2 at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

ANS: B The patient's clinical manifestations and history are consistent with a pulmonary embolism, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient but meeting the physiologic need for O2 is a higher priority. The health care provider should be notified after the O2 is started and pulse oximetry obtained concerning suspected fat embolism or venous thromboembolism.

Which information should the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self-management? a. Symptoms usually progress as patients become older. b. A gradual increase in daily exercise may help decrease fatigue. c. Avoid use of over-the-counter antihistamines or decongestants. d. A low-residue, low-fiber diet will reduce any abdominal distention.

ANS: B A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with SEID syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. SEID usually does not progress.

Which action should the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? a. Instruct the patient to purchase a soft mattress. b. Encourage the patient to 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 associated with RA. Patients are taught to avoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When the disease is stabilized, a physical therapist usually develops a therapeutic exercise program that includes exercises that improve flexibility and strength of affected joints, as well as the patient's general endurance.

Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). What information should the nurse include in teaching the patient about this drug? a. Avoiding aspirin use. b. Giving subcutaneous injections. c. Taking the medication with water. d. Recognizing gastrointestinal bleeding.

ANS: B 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 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.

A patient 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. Red, scaly patches are noted on the arms. b. Crackles are auscultated in the lung bases. c. Hemoglobin is 11.1g/dL, and hematocrit is 35%. d. Patient has continued pain after first week of therapy.

ANS: B 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.

The nurse should determine additional instruction is needed when a patient diagnosed with scleroderma makes which statement? 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 teaching has been effective.

Which laboratory result should the nurse monitor to determine if prednisone has been effective for a patient who has an acute exacerbation of rheumatoid arthritis? a. Blood glucose b. C-reactive protein c. Serum electrolytes d. Liver function tests

ANS: B C-reactive protein is a serum marker for inflammation, and a decrease would indicate the corticosteroid therapy was effective. Blood glucose and serum electrolytes will also be monitored to assess for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids

Which information should the nurse include when preparing teaching materials for a patient who has an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present b. Applying 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.

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

ANS: B Corticosteroids have the potential to cause diabetes. The finding of elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR with no improvement in symptoms would indicate the prednisone was not effective but would not be side effects of the medication.

The nurse is assessing a patient with osteoarthritis who uses naproxen (Naproxyn) for pain management. Which assessment finding should the nurse recognize as likely to require a change in medication? a. The patient has gained 3 pounds. b. The patient has dark-colored stools. c. The patient's pain affects multiple joints. d. The patient uses capsaicin cream (Zostrix).

ANS: B Dark-colored stools may indicate the patient is experiencing gastrointestinal bleeding caused by the naproxen. The patient's ongoing pain and weight gain will also 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.

Which result for a patient with systemic lupus erythematosus (SLE) should the nurse identify as most important 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 Elevated BUN and serum creatinine indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows decreased inflammation.

Which finding should the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? a. Presence of Heberden's nodules b. Discomfort with joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

ANS: B Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests and decreases with joint movement.

The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order should the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Naproxen 200 mg twice daily. 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.

A patient with gout has a new prescription for losartan (Cozaar). What should the nurse plan to monitor? a. Blood glucose b. Blood pressure c. Erythrocyte count d. Lymphocyte count

ANS: B Losartan may be effective for treating older patients with gout and hypertension. Losartan promotes urate excretion and may normalize serum urate. Losartan, an angiotensin II receptor antagonist, should lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.

Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient understands the nurse's 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 avoid nonsteroidal antiinflammatory drugs." d. "I should take birth control pills to avoid getting pregnant."

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.

How should the nurse suggest that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day? a. A brief routine of isometric exercises b. A warm bath followed by a short rest c. Active range-of-motion (ROM) exercises d. Stretching exercises to relieve joint stiffness

ANS: B 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

A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. What safety priority should the nurse identify for this patient? a. Acute pain b. Risk for aspiration c. Impaired tissue integrity d. Disturbed visual perception

ANS: B The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other concerns are also appropriate but are not as high a priority as the maintenance of the patient's airway.

26. A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding should the nurse identify as most important to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

ANS: C A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion should also be reported, but these do not indicate emergent treatment is needed to preserve function.

4. Which discharge instruction should the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.

ANS: C Elevation of the leg will reduce swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.

24. A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? a. Using crutches with a swing-to gait b. Sitting upright on the edge of the bed c. Leaning over to pull on shoes and socks d. Bending over the sink while brushing teeth

ANS: C Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

41. When a patient arrives in the emergency department with a facial fracture, which action should the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

ANS: C Patients who have facial fractures are at risk for cervical spine injury and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.

34. A patient is admitted to the emergency department with a left femur fracture. Which assessment finding by the nurse is most important to report to the health care provider? a. Bruising of the left thigh b. Reports of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot

ANS: C Prolonged capillary refill may indicate complications such as compartment syndrome. The other findings are typical with a left femur fracture.

11. A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which assessment finding should indicate to the nurse a potential complication of the fracture? a. The patient states the pelvis feels unstable. b. The patient reports pelvic pain with palpation. c. Abdomen is distended, and bowel sounds are absent. d. Ecchymoses are visible across the abdomen and hips.

ANS: C The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

21. A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery? a. "This procedure will correct the deformities in my fingers." b. "I will not have to do as many hand exercises after the surgery." c. "I will be able to use my fingers with more flexibility to grasp things." d. "My fingers will appear more normal in size and shape after this surgery."

ANS: C The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

30. After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action should the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Assess leg pulses and sensation. d. Place ice packs on the lower leg.

ANS: C The initial action by the nurse will be to assess circulation to the leg and observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

31. A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. What initial action should the nurse take? a. Elevate the right leg. b. Splint the lower leg. c. Assess the pedal pulses. d. Verify tetanus immunization.

ANS: C The initial nursing action should be assessment of the neurovascular condition of the injured leg. After assessment, the nurse may need to splint and elevate the leg based on the assessment data. Information about tetanus immunizations should be obtained if there is an open wound.

33. The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Check the O2 saturation. c. Assess patient orientation. d. Observe for facial asymmetry.

ANS: C The patient's history and clinical manifestations suggest a fat embolism. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses O2 saturation.

A patient with an acute attack of gout in the right great toe has a new prescription for probenecid. Which information about the patient's home routine should the nurse understand indicates a need for teaching regarding gout management? a. The patient sleeps 8-10 hours each night. b. The patient usually eats beef once a week. c. The patient takes one aspirin a day to prevent angina. d. The patient usually drinks about 3 quarts water each day.

ANS: C Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's 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.

A patient with hypertension and gout has a red, painful right great toe. Which action should the nurse include in the plan of care for this patient? 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 the patient to avoid 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 should be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain management.

A patient is taking methotrexate to treat rheumatoid arthritis (RA). Which laboratory result is important for the nurse to communicate to the health care provider? a. Rheumatoid factor is positive. b. Fasting blood glucose is 90 mg/dL. c. The white blood cell count is 1500/µL. d. The erythrocyte sedimentation rate is increased.

ANS: C Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose is normal.

The nurse should anticipate the need to teach a patient who has osteoarthritis (OA) about which medication? a. Prednisone b. Adalimumab (Humira) 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 rheumatoid arthritis.

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." What is the most appropriate response by the nurse? 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.

A patient who takes multiple medications develops acute gout arthritis. Which medication should the nurse discuss with the health care provider before administering a prescribed dose? a. sertraline (Zoloft). b. famotidine (Pepcid). c. hydrochlorothiazide. d. oxycodone (Roxicodone).

ANS: C Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer

Which information from a patient's health history should the nurse identify as a risk factor for septic arthritis? a. Recently visited South America b. Several knee injuries as a teenager c. Sexually active with several 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.

The nurse teaches a patient with osteoarthritis (OA) of the hip about how to manage the OA. Which patient statement indicates to the nurse a need for additional teaching? a. "A shower in the morning will help relieve stiffness." b. "I can exercise every day to help maintain joint mobility." c. "I will take 1 gram of acetaminophen (Tylenol) every 4 hours." d. "I can use a cane to decrease the pressure and pain in my hip."

ANS: C No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease the risk for liver damage. Regular exercise, moist heat, and supportive equipment are recommended for OA management.

What suggestion should the nurse make to a group of women with rheumatoid arthritis (RA) about managing activities of daily living? a. Protect the knee joints by sleeping with a small pillow under the knees. b. Strengthen small hand muscles by wringing out sponges or washcloths. c. Avoid activities requiring repetitive use of the same muscles and joints. d. Stand rather than sit when performing daily household and yard chores.

ANS: C 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 joint stress. Patients are encouraged to position joints in the extended (neutral) position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion.

A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action should 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.

A new clinic patient with joint swelling and pain is having diagnostic tests. Which test should the nurse identify as specific to systemic lupus erythematosus? 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.

The nurse notices a circular lesion with a red border and clear center on the arm of a patient who is in the clinic reporting chills and muscle aches. Which action should the nurse take to follow up on that finding? a. Auscultate the heart sounds. b. Palpate the abdomen for masses. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.

ANS: C The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest cardiac or abdominal problems or lack of immunization.

A patient with rheumatoid arthritis (RA) tells the clinic nurse about having chronically dry eyes. Which action should the nurse take? a. Ask the HCP about discontinuing methotrexate. b. Remind the patient that RA is a chronic health condition. c. Suggest the patient use over-the-counter (OTC) artificial tears. d. Teach the patient about adverse effects of the RA medications.

ANS: C The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eyedrops is recommended. Dry eyes are not a side effect of methotrexate. A focus on the prognosis for RA is not helpful. The dry eyes are not caused by RA treatment but by the disease itself.

In which order should the nurse complete actions when caring for a patient in the emergency department who has a right leg fracture? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.

ANS: C, D, B, E, A, F The initial actions should be to ensure adequate airway, breathing, and circulation. This should be followed by checking the neurovascular condition of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-ray examination. The tetanus prophylaxis is the least urgent of the actions.

27. A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which prescribed action will the nurse implement first? a. Send the patient for ankle x-rays. b. Administer naproxen (Naprosyn). c. Give acetaminophen with codeine. d. Wrap the ankle and apply an ice pack.

ANS: D Immediate care after a sprain or strain injury includes application of cold and use of compression to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information should the nurse discuss with the health care provider for an urgent change in the treatment plan? a. Knee crepitation is noted with normal knee range of motion. b. Patient reports embarrassment about having Heberden's nodes. c. Patient's 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 be reported to the health care provider but is consistent with the patient's diagnosis of osteoarthritis and will not require an immediate change in the patient's treatment plan.

A patient reporting painful urination and knee pain is diagnosed with reactive arthritis. What long-term therapy should the nurse plan to explain to the patient? a. methotrexate b. anakinra (Kineret) c. etanercept (Enbrel) d. doxycycline (Vibramycin)

ANS: D 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.

The home health nurse is making a follow-up visit to a patient recently diagnosed with rheumatoid arthritis (RA). Which finding indicates to the nurse that additional patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins each day. 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. Rest, aspirin, and energy management are appropriate for a patient with RA and indicate teaching has been effective.

The patient developed gout while hospitalized for a heart attack. When doing discharge teaching for this patient who takes aspirin for its antiplatelet effect, what should the nurse include about preventing future attacks of gout? Limit fluid intake. Administration of probenecid (Benemid) Administration of allopurinol (Zyloprim) Administration of nonsteroidal antiinflammatory drugs (NSAIDs)

Administration of allopurinol (Zyloprim) To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the aspirin the patient must take will inactivate its effect, resulting in urate retention. NSAIDs for pain management will not be used, related to the aspirin, because of the potential for increased side effects.

The 40-year-old African American woman has had Raynaud's phenomenon for some time. She is now reporting red spots on the hands, forearms, palms, face, and lips. What other manifestations should the nurse assess for when she is assessing for scleroderma (select all that apply)? Calcinosis Weight loss Sclerodactyly Difficulty swallowing Weakened leg muscles

Calcinoshs Sclerodactyly Difficulty swallowing This 40-year-old African American woman is at risk for scleroderma. The acronym CREST represents the clinical manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud's phenomenon; E: Esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis not scleroderma.

Because the incidence of Lyme disease is very high in Wisconsin, the public health nurse is planning to provide community education to increase the number of people who seek health care promptly after a tick bite. What information should the nurse provide when teaching people who are at risk for a tick bite? The best therapy for the acute illness is an IV antibiotic. Check for an enlarging reddened area with a clear center. Surveillance is necessary during the summer months only. Antibiotics will prevent Lyme disease if taken for 10 days.

Check for an enlarging reddened area with a clear center. Following a tick bite, the expanding "bull's eye rash" is the most characteristic symptom that usually occurs in 3 to 30 days. There may also be flu-like symptoms and migrating joint and muscle pain. Active lesions are treated with oral antibiotics for 2 to 3 weeks, and doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors.

A patient presents to the clinical after tripping on a curb and spraining the right ankle. Which initial care measures are appropriate? (Select all that apply.) Apply ice directly to the skin. Apply heat to the ankle every 2 hours. Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Perform passive and active range of motion.

Correct Answer: Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Rationale: Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Antiinflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.

A patient with a fracture of the proximal left tibia in a long leg cast reports of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? Notify the health care provider immediately. Elevate the left leg above the level of the heart. Administer prescribed morphine sulfate intravenously. Apply ice packs to the left proximal tibia over the cast.

Correct Answer: Notify the health care provider immediately. Rationale: Notify the health care provider immediately of this change in patient's condition, which suggests development of compartment syndrome. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Changes in sensation (tingling) also suggest compartment syndrome. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Administration of morphine may be warranted, but it is not the first priority.

A nurse is working with a 73-year-old patient with osteoarthritis (OA). In assessing the patient's understanding of this disorder, the nurse concludes teaching has been effective when the patient uses which description of the condition? Joint destruction caused by an autoimmune process Degeneration of articular cartilage in synovial joints Overproduction of synovial fluid resulting in joint destruction Breakdown of tissue in non-weight-bearing joints by enzymes

Degeneration of articular cartilage in synovial joints OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.

The nurse is caring for a patient who has osteoarthritis (OA) of the knees. The nurse teaches the patient that the most beneficial measure to protect the joints is to do what? Use a wheelchair to avoid walking as much as possible. Sit in chairs that cause the hips to be lower than the knees. Eat a well-balanced diet to maintain a healthy body weight. Use a walker for ambulation to relieve the pressure on the hips.

Eat a well-balanced diet to maintain a healthy body weight. Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The chairs that would be best for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for OA of the knees.

The nurse teaches a 64-year-old man with gouty arthritis about food that may be consumed on a low-purine diet. Which food item, if selected by the patient, would indicate an understanding of the instructions? Eggs Liver Salmon Chicken

Eggs Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.

The patient brought to the emergency department after a car accident is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? Administer enoxaparin (Lovenox). Provide range-of-motion exercises. Apply sequential compression boots. Immobilize the fracture preoperatively

Immobilize the FX preop Rationale: The urse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots, not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

The patient with fibromyalgia is suffering with pain at 12 of the 18 identification sites, including the neck and upper back and the knees. The patient also reports nonrefreshing sleep, depression, and being anxious when dealing with multiple tasks. The nurse should teach this patient about what treatments (select all that apply)? Low-impact aerobic exercise Relaxation strategy (biofeedback) Antiseizure drug pregabalin (Lyrica) Morphine sulfate extended-release tablets Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

Low-impact aerobic exercise Relaxation strategy (biofeedback) Antiseizure drug pregabalin (Lyrica) Serotonin reuptake inhibitor (e.g., sertraline [Zoloft]) Because the treatment of fibromyalgia is symptomatic, this patient will be prescribed something for pain, such as pregabalin, and a serotonin reuptake inhibitor for depression. Low- impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation can help decrease the patient's stress and anxiety. Long-acting opioids are generally avoided unless pain cannot be relieved by other medications.

A nurse assesses a 38-year-old patient with joint pain and stiffness who was diagnosed with Stage III rheumatoid arthritis (RA). What characteristics should the nurse expect to observe (select all that apply)? Nodules present Consistent muscle strength Localized disease symptoms Incorrect No destructive changes on x-ray Subluxation of joints without fibrous ankylosis

Nodules present Subluxation of joints without fibrous ankylosis In Stage III severe RA, there may be extraarticular soft tissue lesions or nodules present, and there is subluxation without fibrous or bony ankylosis. The muscle strength is decreased because there is extensive muscle atrophy. The manifestations are systemic not localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Awarded 1.0 points out of 2.0 possible points.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Which finding should the nurse expect to be present on examination of the patient's knees? Ulnar drift Pain with joint movement Reddened, swollen affected joints Stiffness that increases with movement

Pain with joint movement OA is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis (RA) not osteoarthritis. Not all joints are reddened or swollen. Only Heberden's and Bouchard's nodes may be. Stiffness decreases with movement.

A nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes which activity pattern? Bed rest with bathroom privileges Daily high-impact aerobic exercise Regular exercise program of walking Frequent rest periods with minimal exercise

Regular exercise program of walking A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in the patient with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

7. What should be included in the management during the first 48 hours after an acute soft tissue injury of the ankle (select all that apply)? a. Use of elastic wrap b. Initial immobilization and rest c. Elevation of ankle above the heart d. Alternating the use of heat and cold e. Administration of antiinflammatory drugs

a, b, c, e. Consider the principle of RICE. Rest: movement should be restricted. Ice: cold should be used to promote vasoconstriction and reduce edema. Compression: helps decrease swelling. Elevate: the extremity above the level of the heart. Mild nonsteroidal antiinflammatory drugs (NSAIDs) may be needed to manage pain. Warm, moist compresses may be used after 48 hours for 20 to 30 minutes at a time to reduce swelling and provide comfort.

A patient with debilitating fatigue has been diagnosed with systemic exertion intolerance disease (SEID). Which criteria are considered the three major symptoms and the one additional manifestation that must be present for this diagnosis to be made (select all that apply)? a. Unrefreshing sleep b. Unexplained muscle pain c. Cognitive impairment ("brain fog") d. Profound fatigue lasting for 6 months e. Tender cervical or axillary lymph nodes f. Headaches of a new type, pattern, or severity g. Total exhaustion after minor physical or mental exertion

a, c, d, g.

22. What emergency considerations must be included with facial fractures (select all that apply)? a. Airway patency b. Oral examination c. Cervical spine injury d. Cranial nerve assessment e. Immobilization of the jaw

a, c. Airway patency and cervical spinal cord injury are the emergency considerations with facial fractures. Oral examination and cranial nerve assessment will be done after the patient is stabilized. Immobilization of the jaw is done surgically for a mandibular fracture.

A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? a. "Infertility can result from some medications used to control your disease." b. "Temporary remission of your signs and symptoms is common during pregnancy." c. "Autoantibodies transferred to the baby during pregnancy will cause heart defects." d. "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth."

a. "Infertility can result from some medications used to control your disease." Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common after pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.

Patient-Centered Care: What should the nurse include in the teaching plan for the patient with SLE? a. Ways to avoid exposure to sunlight b. Increasing dietary protein and carbohydrate intake c. The necessity of genetic counseling before planning a family d. The use of nonpharmacologic pain interventions instead of analgesics

a. Acute exacerbations of SLE may be precipitated by overexposure to ultraviolet light, physical and emotional stress, fatigue, and infection or surgery. Dietary recommendations include small, frequent meals and adequate iron intake. Although SLE has an identified genetic association with HLA-DR2 and HLA-DR3, genetic counseling is not a usual recommendation. The major concern in planning a pregnancy is that there are increased risks for the mother and fetus during pregnancy, and exacerbations are common following delivery. Although nonpharmacologic methods of pain control are encouraged, the use of NSAIDs is often necessary to help control inflammation and pain.

A 40-yr-old African American woman has longstanding Raynaud's phenomenon. Currently, she reports red spots on her hands, forearms, palms, face, and lips. Which additional findings will the nurse expect (select all that apply)? a. Calcinosis b. Weight loss c. Sclerodactyly d. Difficulty swallowing e. Weakened leg muscles f. Skin thickening below the elbow and knee

a. Calcinosis c. Sclerodactyly d. Difficulty swallowing f. Skin thickening below the elbow and knee This patient is at risk for scleroderma. The acronym CREST represents the clinical manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud's phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.

Patient-Centered Care: A patient taking ibuprofen for treatment of OA has good pain relief but is experiencing increased dyspepsia and nausea with the drug's use. The nurse consults the patient's HCP about doing what? a. Adding misoprostol to the patient's drug regimen b. Substituting naproxen (Naprosyn) for the ibuprofen c. Returning to the use of acetaminophen but at a dose of 5 g/day instead of 4 g/day d. Administering the ibuprofen with antacids to decrease the gastrointestinal (GI) irritation

a. Common side effects of nonsteroidal antiinflammatory drugs (NSAIDs) include gastrointestinal (GI) irritation and bleeding, dizziness, rash, headache, and tinnitus. Misoprostol is used to prevent NSAID-induced gastric ulcers and gastritis and would increase the patient's tolerance of any of the NSAIDs. The use of naproxen could cause the same gastric effects as ibuprofen. It is generally recommended that the daily dose of acetaminophen should not exceed 3 g/day to prevent liver damage. Antacids interfere with the absorption of NSAIDs.

During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the corticosteroids to begin to be tapered when which serum laboratory results are evident? a. Decreased anti-DNA b. Increased complement c. Increased red blood cells (RBCs) d. Decreased erythrocyte sedimentation rate (ESR)

a. Efficacy of treatment with corticosteroids or immunosuppressive drugs is best monitored by serial anti-DNA titers and serum complement levels, both of which will decrease as the drugs have an effect. The patient with SLE often has a chronic anemia that is not affected by drug therapy. A reduction in erythrocyte sedimentation rate (ESR) is not as specific.

The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient's choice of which food item would indicate an understanding of the instructions? a. Eggs b. Liver c. Salmon d. Chicken

a. Eggs Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.

What characterizes the pathophysiology of systemic lupus erythematosus (SLE)? a. Destruction of nucleic acids and other self-proteins by autoantibodies b. Overproduction of collagen that disrupts the functioning of internal organs c. Formation of abnormal IgG that attaches to cellular antigens, activating complement d. Increased activity of T suppressor cells with B-cell hypoactivity, resulting in an immunodeficiency

a. In systemic lupus erythematosus (SLE), autoantibodies are produced against nucleic acids, erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins. This is a hypersensitive response, not immunodeficiency. Overproduction of collagen is characteristic of systemic sclerosis and abnormal IgG reactions with autoantibodies are characteristic of RA.

A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient also reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments will be included in the plan of care (select all that apply)? a. Massage therapy b. Low-impact aerobic exercise c. Relaxation strategy (biofeedback) d. Antiseizure drug pregabalin (Lyrica) e. Morphine sulfate extended-release tablets f. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

a. Massage therapy b. Low-impact aerobic exercise c. Relaxation strategy (biofeedback) d. Antiseizure drug pregabalin (Lyrica) f. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft]) Massage will improve blood flow and relaxation. Low-impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation using biofeedback may decrease the patient's stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will preferably be prescribed a nonopioid pain medication, an antiseizure medication such as pregabalin to help with widespread pain, and a serotonin reuptake inhibitor for depression. Long-acting opioids such as morphine are generally avoided unless pain cannot be relieved by other medications.

Which description is most characteristic of osteoarthritis (OA) when compared to rheumatoid arthritis (RA)? a. Not systemic or symmetric b. Rheumatoid factor (RF) positive c. Most commonly occurs in women d. Morning joint stiffness lasts 1 to several hours

a. OA is not systemic or symmetric. In OA, morning joint stiffness resolves in about 30 minutes. Rheumatoid arthritis (RA) is rheumatoid factor (RF) positive, occurs more in women than men,and is characterized by being systemic and affecting small joints symmetrically. In RA, morning joint stiffness lasts 60 minutes to all day.

Four patients have been newly diagnosed with connective tissue disorders. The nurse should be aware of safety issues and interstitial lung involvement for the patient with which diagnosis? a. Polymyositis b. Reactive arthritis c. Sjögren's syndrome d. Systemic lupus erythematosus (SLE)

a. Polymyositis Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient's risk of falls and injury. Weakened pharyngeal muscles also increase the risk for aspiration, with interstitial lung disease in up to 65% of patients. Safety concerns and interstitial lung involvement are not associated with reactive arthritis (Reiter's syndrome) or Sjögren's syndrome. Safety may be an issue later in disease progression of SLE.

A nurse assesses a 38-yr-old patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect (select all that apply)? a. Presence of nodules b. Consistent muscle strength c. Localized disease symptoms d. No destructive changes on x-ray e. Subluxation of joints without fibrous ankyloses f. Joint space narrowing and formation of osteophytes

a. Presence of nodules e. Subluxation of joints without fibrous ankyloses In stage III severe RA, extraarticular soft tissue lesions or nodules may be present along with subluxation without fibrous or bony ankylosis. Muscle strength is decreased because of extensive muscle atrophy. Manifestations are systemic rather than localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Joint space narrowing with osteophytes is consistent with osteoarthritis.

During assessment of the patient with scleroderma, what should the nurse expect to find? a. Thickening of the skin of the fingers and hands b. Cool, cyanotic fingers with thinning skin over the joints c. Swan neck deformity or ulnar drift deformity of the hands d. Low back pain, stiffness, and limitation of spine movement

a. Scleroderma is a disorder of connective tissue that causes skin thickening and tightening, resulting in symmetric, painless swelling or thickening of the skin of the fingers and hands, expressionless facial features, puckering of the mouth, and a small oral orifice. It does not cause the swan neck or ulnar drift deformities seen in RA or SLE. Low back pain and spinal stiffness are associated with ankylosing spondylitis.

19. If surgery is needed, which procedure would the nurse first prepare the patient for in the presence of compartment syndrome? a. Fasciotomy b. Amputation c. Internal fixation d. Release of tendons

a. Soft tissue edema in the area of the injury may cause increased pressure within the closed tissue compartments formed by the nonelastic fascia, causing compartment syndrome. If symptoms occur, surgical incision of fascia may be needed (fasciotomy). Amputation is usually needed only if the limb becomes septic because of untreated compartment syndrome.

A patient with OA asks the nurse whether he could try glucosamine and chondroitin for control of his symptoms. The best response by the nurse includes what information? a. Some patients find these supplements helpful for relieving arthritis pain and improving mobility. b. Although these substances may not help, there is no evidence that they can cause any untoward effects. c. These supplements are a fad that has not been shown to reduce pain or increase joint mobility in patients with OA. d. Only dosages of these supplements available by prescription are high enough to provide any benefit in treatment of OA.

a. Some obtain relief for moderate to severe osteoarthritic pain but not for all patients using over- the-counter glucosamine and chondroitin sulfate. These substances should be discontinued if there are no effects after consistent use over 90 to 120 days. They may decrease the effectiveness of antidiabetic drugs and increase the risk of bleeding.

A patient with a pelvic fracture should be monitored for... a. changes in urine output b. petechiae on the abdomen c. a palpable lump in the buttock d. sudden increase in blood pressure

a. changes in urine output Rationale: Pelvic fractures may cause serious intraabdominal injury, such as hemorrhage, and laceration of the urethra, bladder, or colon. Patients may survive the initial pelvic injury, only to die of sepsis, FES, or VTE. Because a pelvic fracture can damage other organs, the nurse should assess bowel and urinary elimination and distal neurovascular status.

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 c. root vegetables

a. sugar b. alcohol c. caffeine Rationale: Dietitians often urge patients with fibromyalgia to limit their intake of sugar, caffeine, and alcohol because these substances have been shown to be muscle irritants.

A 66-yr-old man with type 2 diabetes mellitus and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask? a. "Did you have any hypoglycemic reactions?" b. "Have you noticed any bruising or bleeding?" c. "Have you had any dizzy spells when standing up?" d. "Do you have any numbness or tingling in your feet?"

b. "Have you noticed any bruising or bleeding?" Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both may increase the risk of bleeding. Patients with atrial fibrillation routinely take an anticoagulant to reduce the risk of venous thromboembolism and stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose, and hyperglycemia may occur.

The patient has had RA for some time but has not had success with previous medications. Although there is an increased risk for tuberculosis, which tumor necrosis factor (TNF) inhibitor is used with methotrexate to best treat symptoms? a. Parenteral gold b. Certolizumab (Cimzia) c. Tocilizumab (Actemra) d. Hydroxychloroquine (Plaquenil)

b. Certolizumab is a monoclonal antibody that is a TNF inhibitor and stays in the system longer and may show a more rapid reduction in RA symptoms. Parenteral gold alters immune responses that may suppress synovitis of active RA, but it takes 3 to 6 months to be effective. Tocilizumab blocks the action of the proinflammatory cytokine interleukin-6 (IL-6). Hydroxychloroquine is slow-acting antimalaria drug used initially for mild RA and requires periodic eye examinations to assess for retinal damage.

The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites? a. The best therapy for the acute illness is an IV antibiotic. b. Check for an enlarging reddened area with a clear center. c. Surveillance is necessary during the summer months only. d. Antibiotics will prevent Lyme disease if taken for 10 days.

b. Check for an enlarging reddened area with a clear center. After a tick bite, the expanding "bull's eye rash" is the most characteristic symptom that usually occurs in 3 to 30 days. Flu-like symptoms and migrating joint and muscle pain also may be present. Active lesions are treated with oral antibiotics for 2 to 3 weeks; doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. No vaccine is available.

During treatment of the patient with an acute attack of gout, the nurse would expect to administer which drug first? a. Aspirin b. Colchicine c. Probenecid d. Allopurinol (Zyloprim)

b. Colchicine has an antiinflammatory action specific for gout and is the treatment of choice during an acute attack, often producing dramatic pain relief when given within 12 to 24 hours. Probenecid is a uricosuric drug that is used to control hyperuricemia by increasing the excretion of uric acid through the kidney. Aspirin inactivates the effect of uricosuric drugs and should not be used when patients are taking probenecid and other uricosuric drugs. Allopurinol, a xanthine oxidase inhibitor, is used to control hyperuricemia by blocking production of uric acid.

41. After a total knee arthroplasty, a patient has a continuous passive motion (CPM) machine for the affected joint. What should the nurse explain to the patient is the purpose of this device? a. To relieve edema and pain at the incision site b. To promote early joint mobility and increase knee flexion c. To prevent venous stasis and the formation of a deep venous thrombosis d. To improve arterial circulation to the affected extremity to promote healing

b. Continuous passive motion (CPM) machines may be used after knee surgery to promote early joint mobility. Because joint dislocation is not a problem with knee replacements, early ambulation to prevent deep vein thrombosis (DVT) and improve circulation, exercise with straight leg raises, and gentle ROM maybe encouraged postoperatively.

10. A patient is brought to the emergency department (ED) with an injured lower left leg following a fall while rock climbing. The nurse identifies the presence of a fracture based on what cardinal sign of fracture? a. Muscle spasms b. Obvious deformity c. Edema and swelling d. Pain and tenderness

b. Deformity is the cardinal sign of fracture but may not be apparent in all fractures. Other supporting signs include edema and swelling, localized pain and tenderness, muscle spasm, ecchymosis, loss of function, crepitation, and an inability to bear weight.

A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan? a. Joint destruction caused by an autoimmune process b. Degeneration of articular cartilage in synovial joints c. Overproduction of synovial fluid resulting in joint destruction d. Breakdown of tissue in non-weight-bearing joints by enzymes

b. Degeneration of articular cartilage in synovial joints OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.

40. When positioning the patient after a total hip arthroplasty with a posterior approach, it is important that the nurse maintain the affected extremity in what position? a. Adduction and flexion b. Abduction and extension c. Abduction and internal rotation d. Adduction and external rotation

b. During hospitalization, after a total hip arthroplasty with a posterior approach, an abduction pillow is placed between the legs to maintain abduction and the leg is extended. Extremes of internal rotation, adduction, and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively to prevent dislocation of the prosthesis.

A patient with gout is treated with drug therapy to prevent future attacks. The nurse teaches the patient that what is most important for the patient to do? a. Avoid all foods high in purine, such as organ meats. b. Have periodic determination of serum uric acid levels. c. Increase the dosage of medication with the onset of an acute attack. d. Perform active range of motion (ROM) of all joints that have been affected by gout.

b. During therapy with probenecid or allopurinol, the patient must have periodic determination of serum uric acid levels to evaluate the effectiveness of the therapy and to ensure that levels are kept low enough to prevent future attacks of gout. With the use of medications, strict dietary restrictions on alcohol and high-purine foods are usually not necessary. When the patient is taking probenecid, urine output should be maintained at 2 to 3 L per day to prevent urate from precipitating in the urinary tract and causing kidney stones. Patients should not alter their doses of medications without medical direction, and the drugs used for control of gout are not useful in the treatment of an acute attack. Joint immobilization is used for an acute attack of gout.

When administering medications to the patietn 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. Febuxostat Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for long-term management of hyperuricemia in persons with chronic gout. An acute episode of gout is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs).

After teaching a patient with RA about the prescribed therapeutic regimen, the nurse determines that further instruction is needed when the patient says what? a. "It is important for me to perform my prescribed exercises every day." b. "I should perform most of my daily chores in the morning when my energy level is highest." c. "An ice pack to a joint for 10 minutes may help to relieve pain and inflammation when I have an acute flare." d. "I can use assistive devices such as padded utensils, electric can openers, and elevated toilet seats to protect my joints."

b. Most patients with RA experience morning stiffness, and morning activities should be scheduled later in the day after the stiffness subsides. A warm shower in the morning and time to become more mobile before activity are advised. Ice for 10 minutes or splinting are helpful during increased disease activity. Management of RA includes daily exercises for the affected joints and protection of joints with devices and movements that prevent joint stress.

Patient-Centered Care: A patient recovering from an acute exacerbation of RA tells the nurse that she is too tired to bathe. What should the nurse do for this patient? a. Give the patient a bed bath to conserve her energy. b. Allow the patient a rest period before showering with the nurse's help. c. Tell the patient that she can skip bathing if she will walk in the hall later. d. Inform the patient that it is important for her to maintain self-care activities.

b. Pacing activities and alternating rest with activity are important in maintaining self-care and independence of the patient with RA, in addition to preventing deconditioning and a negative attitude. The nurse should not carry out activities for patients that they can do for themselves but instead should support and assist patients as necessary. A warm shower or sitting in a tub with warm water and towels over the shoulders may help to relieve some stiffness.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient's knees? a. Ulnar drift b. Pain with joint movement c. Reddened, swollen affected joints d. Stiffness that increases with movement

b. Pain with joint movement Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.

Priority Decision: A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. What is the best response the nurse can give the patient? a. "You can plan to have a near-normal life since SLE rarely causes death." b. "It is difficult to tell because the disease is so variable in its severity and progression." c. "Life span is shortened somewhat in people with SLE, but the disease can be controlled with long-term use of corticosteroids." d. "Most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage."

b. Patients with SLE often find that one of the most difficult facets of the disease is its extreme variability in severity and progression. There is no characteristic pattern of progressive organ involvement, nor is it predictable as to which systems may become affected. SLE is now associated with a normal life span, but patients must be helped to adjust to the unknown course of the disease.

During assessment of the patient diagnosed with fibromyalgia, along with widespread pain, what should the nurse expect the patient to report? a. Generalized muscle twitching and spasms b. Nonrestorative sleep with resulting fatigue c. Profound and progressive muscle weakness that limits ADLs d. Widespread musculoskeletal pain that is accompanied by inflammation and fever

b. People with fibromyalgia typically experience nonrestorative sleep, morning stiffness, irritable bowel syndrome, and anxiety in addition to the widespread, nonarticular musculoskeletal pain and fatigue. Fibromyalgia is nondegenerative, nonprogressive, and noninflammatory. Neither muscle weakness nor muscle spasms are associated with the disease, although there may be tics in the muscle at the tender points.

33. A patient reports pain in the foot of a leg that was recently amputated. What should the nurse recognize about this pain? a. It is caused by swelling at the incision. b. It should be treated with ordered analgesics. c. It will become worse with the use of a prosthesis. d. It can be managed with diversion because it is psychologic.

b. Phantom limb sensation or pain may occur after amputation, especially if pain was present in the affected limb preoperatively, and is a real sensation to the patient. It will first be treated with analgesics and other pain interventions (i.e., tricyclic antidepressants, antiseizure drugs, transcutaneous electrical nerve stimulation [TENS], mirror therapy, acupuncture). As recovery and ambulation progress, phantom limb sensation usually subsides.

Patient-Centered Care: To preserve function and the ability to perform activities of daily living (ADLs), what should the nurse teach the patient with OA? a. Avoid exercise that involves the affected joints. b. Plan and organize task performance to be less stressful to joints. c. Maintain normal activities during an acute episode to prevent loss of function. d. Use mild analgesics to control symptoms when performing tasks that cause pain.

b. Principles of joint protection and energy conservation are critical in being able to maintain functional mobility in the patient with OA, and patients should be helped to find ways to perform activities and tasks with less stress. Range-of-motion (ROM), isotonic, and isometric exercises of the affected joints should be balanced with joint rest and protection but during an acute flare of joint inflammation, the joints should be rested. If a joint is painful, it should be used only to the point of pain and masking the pain with analgesics may lead to greater joint injury.

6. Application of RICE (rest, ice, compression, elevation) is indicated for initial management of which type of injury? a. Muscle spasms b. Sprains and strains c. Repetitive strain injury d. Dislocations and subluxations

b. Rest, ice, compression, and elevation (RICE) are indicated to decrease edema resulting from sprains and some strains. Muscle spasms are usually treated with heat application and massage. Repetitive strain injuries require cessation of the precipitating activity and physical therapy. Dislocations or subluxations require immediate reduction and immobilization to prevent vascular impairment and bone cell death.

Which other extraarticular manifestation of RA is most likely to be seen in the patient with rheumatoid nodules? a. Lyme disease b. Felty syndrome c. Sjögren's syndrome d. Spondyloarthropathies

b. Rheumatoid nodules develop in about half of patients with RA. Felty syndrome is most common in patients with long-standing RA. It is characterized by splenomegaly and leukopenia. Sjögren's syndrome occurs as a disease by itself or with other arthritic disorders. Lyme disease is a spirochetal infection transmitted by an infected deer tick bite. Spondyloarthropathies are interrelated multisystem inflammatory disorders that affect the spine, peripheral joints, and periarticular structures but they do not have serum antibodies

14. Priority Decision: A patient is admitted with an open fracture of the tibia after a bicycle accident. What question should the nurse ask when assessing the patient? a. Any previous injuries to the leg b. The status of tetanus immunization c. The use of antibiotics in the last month d. Whether the injury was exposed to dirt or gravel

b. Tetanus prevention is always indicated if the patient has not been immunized or does not have a current booster. Infection is the greatest risk with an open fracture, and all open fractures are considered contaminated. Although prophylactic antibiotics are used in management of open fractures, neither recent antibiotic therapy nor previous injury to the site is relevant. Dirt or gravel contamination will be evident on physical assessment.

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. indicate osteophyte formation at the PIP joints Rationale: Bouchard's nodes are bony deformities of the proximal interphalangeal joints that indicate osteophyte formation and loss of joint space in osteoarthritis.

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. metatarsal head disclocation in feet c. noninflammatory pain in large joints Rationale: Morning stiffness may last from 60 minutes to several hours or more, depending on disease activity. Metatarsal head dislocation and subluxation in the feet may cause pain and walking disability. Joint symptoms occur symmetrically and frequently affect the small joints of the hands (proximal interphalangeal [PIP] and metacarpophalangeal [MCP] joints) and feet (metatarsophalangeal [MTP] joints). Larger peripheral joints such as the wrists, elbows, shoulders, knees, hips, ankles, and jaw may also be involved. Rheumatoid arthritis (RA) is an inflammatory disorder. In early disease, the fingers may become spindle-shaped from synovial hypertrophy and thickening of the joint capsule.

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains the purpose of this procedure is to... (select all that apply) a. fuse the joint b. replace the joint c. prevent further damage d. improve or maintain ROM e. decrease the amount of destruction in the joint

b. replace the joint d. improve or maintain ROM Rationale: Arthroplasty is the reconstruction or replacement of a joint. This surgical procedure is performed to relieve pain, improve or maintain range of motion, and correct deformity. Total hip arthroplasty (THA) provides significant pain relief and improved function for a patient with osteoarthritis (OA).

The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement? a. "I perform range of motion exercises at least twice a day." b. "I use a heating pad for 20 minutes to reduce morning stiffness." c. "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." c. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

c. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)." Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

When reinforcing health teaching on management of osteoarthritis (OA), which patient statement indicates additional instruction is needed? a. "I can use a cane to relieve the pressure on my back and hip." b. "I should take the Naprosyn as prescribed to help control the pain." c. "I should try to stay standing all day to keep my joints from becoming stiff." d. "A warm shower in the morning will help relieve the stiffness I have when I get up."

c. "I should try to stay standing all day to keep my joints from becoming stiff." Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.

A female patient's complex symptomatology over the past year has led to a diagnosis of systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? a. "I'll try my best to stay out of the sun this summer." b. "I know that I have a high chance of getting arthritis." c. "I'm hoping surgery will be an option for me in the future." d. "I understand I'm going to be vulnerable to getting infections."

c. "I'm hoping surgery will be an option for me in the future." Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.

The patient developed gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout? a. Limited fluid intake. b. Administration of probenecid c. Administration of allopurinol d. Administration of nonsteroidal antiinflammatory drugs (NSAIDs)

c. Administration of allopurinol To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the patient's aspirin will inactivate its effect, resulting in urate retention. NSAIDs for pain management will not be used, related to the aspirin, because of the potential for increased side effects.

What is an ominous sign of advanced SLE disease? a. Proteinuria from early glomerulonephritis b. Anemia from antibodies against blood cells c. Dysrhythmias from fibrosis of the atrioventricular node d. Cognitive dysfunction from immune complex deposit in the brain

c. All body systems are affected by SLE. When the atrioventricular and sinus nodes are fibrosed and dysrhythmias occur, this is ominous. Although lupus nephritis can occur and lead to chronic kidney disease, treatment is available. Anemia, mild leukopenia, and thrombocytopenia are often present. Disordered thought processes, disorientation, memory deficits, and depression may occur.

38. When the nursing student asks the registered nurse (RN) what an arthroplasty is, what is the best description the RN can give the student? a. Surgical fusion of a joint to relieve pain b. Correction of bone deformity by removal of a wedge or slice of bone c. Reconstruction or replacement of a joint to relieve pain and correct deformity d. Used in rheumatoid arthritis to remove the tissue involved in joint destruction

c. An arthroplasty is reconstruction or replacement of a joint to relieve pain and correct deformity, especially with osteoarthritis, RA, avascular necrosis, congenital deformity, or dislocation. Arthrodesis is the surgical fusion of a joint to relieve pain. An osteotomy removes a wedge of bone to correct a bone deformity. Synovectomy is used in RA to remove the tissue involved in joint destruction.

A 70-yr-old patient is being evaluated for symptoms of RA. The nurse recognizes what as the major problem in the management of RA in the older adult? a. RA is usually more severe in older adults. b. Older patients are not as likely to comply with treatment regimens. c. Drug interactions and toxicity are more likely to occur with multidrug therapy. d. Laboratory and other diagnostic tests are not effective in identifying RA in older adults.

c. Because older adults are more likely to take many drugs, the use of multidrug therapy in RA is particularly problematic because of the increased likelihood of adverse drug interactions and toxicity. Rheumatic disorders affect younger and older adults. Older adults are not less compliant with drug regimens but may need help with complex regimens. Interpretation of laboratory values in older adults is more difficult in diagnosing RA because of age-related serologic changes, but the disease can be diagnosed.

37. Which joint surgery is used to arthroscopically remove devitalized tissue in joints? a. Osteotomy b. Arthrodesis c. Debridement d. Synovectomy

c. Debridement removes devitalized tissue from joints. Osteotomy corrects bone deformity by removal of a wedge or slice of bone. Arthrodesis surgically fuses a joint to relieve pain. Synovectomy removes tissue involved in joint destruction from rheumatoid arthritis (RA).

The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure will the nurse recommend to slow progression of the disease? a. Use a wheelchair to avoid walking as much as possible. b. Sit in chairs that cause the hips to be lower than the knees. c. Eat a well-balanced diet to maintain a healthy body weight. d. Use a walker for ambulation to relieve the pressure on the hips.

c. Eat a well-balanced diet to maintain a healthy body weight. Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.

During the physical assessment of the patient with early to moderate RA, what should the nurse expect to find? a. Hepatomegaly b. Heberden's nodes c. Spindle-shaped fingers d. Crepitus on joint movement

c. In early disease, the fingers of the patient with moderate RA may become spindle shaped from synovial hypertrophy and thickening of the joint capsule, have no joint deformities but may have limited joint mobility, have adjacent muscle atrophy, and may be inflamed. Splenomegaly may be found with Felty syndrome in patients with severe nodule-forming RA. Heberden's nodes and crepitus on movement are associated with osteoarthritis.

16. How should the nurse assess the neurologic status of the patient with a fractured humerus? a. Have the patient evert, invert, dorsiflex, and plantar flex the foot. b. Assess the location, quality, and intensity of pain below the site of the injury. c. Have the patient abduct the fingers, oppose the thumb and fingers, and flex and extend the wrist. d. Assess the color, temperature, capillary refill, peripheral pulses, and edema in the extremity.

c. Neurologic assessment includes evaluation of sensation, motor function, and pain in the upper extremity. Ask the patient to abduct the fingers (ulnar nerve), oppose the thumb and small fingers (median nerve), and flex and extend the wrist (or fingers if in a cast) (radial nerve). The nurse will assess pain and sensory function in the fingers. Evaluation of the feet would occur in lower extremity injuries. Assessment of color, temperature, capillary refill, peripheral pulses, and edema evaluates vascular condition.

25. What assessment findings distinguish a fat embolism from a pulmonary embolism in a patient with a fracture? a. Tachycardia and dyspnea b. A sudden onset of chest pain c. Petechiae around the neck and upper chest d. Electrocardiographic (ECG) changes and decreased partial pressure of oxygen in arterial blood (PaO2)

c. Patients with fractures are at risk for both fat embolism and pulmonary embolism from VTE, but there is a difference in the time of occurrence. Fat embolism occurs shortly after the injury and thrombotic embolism occurring several days after immobilization. They both may cause pulmonary symptoms of chest pain, tachypnea, dyspnea, apprehension, tachycardia, and cyanosis. However, only fat embolism may cause petechiae found around the neck, anterior chest wall, axilla, buccal membrane of the mouth, and conjunctiva of the eye.

A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern will the nurse recommend? a. Bed rest with bathroom privileges b. Daily high-impact aerobic exercise c. Regular exercise program of walking d. Frequent rest periods with minimal exercise

c. Regular exercise program of walking A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

What is one criterion identified by the American College of Rheumatology for a diagnosis of fibromyalgia? a. Fiber atrophy found on muscle biopsy b. Elimination of all other causes of musculoskeletal pain c. The elicitation of pain on palpation of at least 11 of 18 identified tender points d. The presence of the manifestations of systemic exertion intolerance disease (SEID)

c. The American College of Rheumatology identifies two criteria for the diagnosis of fibromyalgia: (1) pain is experienced in 11 of the 18 tender points on palpation and (2) the patient has a history of widespread pain for at least 3 months. The other findings may also be present but are not diagnostic for fibromyalgia.

The nurse teaches the patient with RA that which exercise is one of the most effective methods of aerobic exercise? a. Ballet dancing b. Casual walking c. Aquatic exercises d. Low-impact aerobic exercises

c. The best aerobic exercise is aquatic exercises in warm water to allow easier joint movement because of the buoyancy of the water. Water produces more resistance and can strengthen the muscles. Tai Chi is also a good form of gentle, stretching exercise that would be appropriate. Dancing and walking impact the joints of the feet and even low-impact aerobics could be damaging. Exercises for patients with RA should be gentle.

31. When preparing a patient for discharge after intermaxillary fixation of a mandibular fracture, which statement indicates that patient teaching has been successful? a. "I can keep my mouth moist by sucking on hard candy." b. "I should cut the wires with scissors if I begin to vomit." c. "I may use a bulk-forming laxative if my liquid diet causes constipation." d. "I should use a moist swab to clean my mouth every time I eat something."

c. The low-bulk, high-carbohydrate liquid diet and intake of air through a straw after mandibular fixation often lead to constipation and flatus, which may be relieved with bulk-forming laxatives, prune juice, and ambulation. Hard candy should not be held in the mouth. Wires or rubber bands should be cut only in the case of cardiac or respiratory arrest, and the patient should be taught to clear the mouth of vomitus or secretions. The mouth should be thoroughly cleaned with water, saline, or alkaline mouthwashes or using a Water Pik as necessary to remove food debris.

Priority Decision: A 60-yr-old woman has pain on motion in her fingers and asks the nurse whether this is just a result of aging. What information is the best response by the nurse? a. Joint pain with functional limitation is a normal change that affects all people to some extent. b. Joint pain that develops with age is usually related to previous trauma or infection of the joints. c. This is a symptom of a systemic arthritis that eventually affects all joints as the disease progresses. d. Changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age.

d. Cartilage destruction in the joints affects the majority of those affected by the age of 40 and when the destruction becomes symptomatic, osteoarthritis (OA) is said to be present. Degenerative changes cause symptoms after age 50 or 60 but more than half over age 65 have x- ray evidence of OA. Joint pain and functional disability should not be considered a normal finding in aging persons. OA is not a systemic disease but may be caused by a known event or condition that directly damages cartilage or causes joint instability (e.g., menopause, obesity).

After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when what is said by the patient? a. "Heat treatments should not be used if muscle spasms are present." b. "Cold applications can be applied for 25 to 30 minutes to relieve joint stiffness." c. "I should use heat applications for 25 minutes to relieve the symptoms of an acute flare." d. "When my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain."

d. Cold therapy is indicated to relieve pain during an acute inflammation, can be applied with frozen packages of vegetables, and should last only 10 to 15 minutes at a time. Heat in the form of heating pads, moist warm packs, paraffin baths, or warm baths or showers is indicated to relieve stiffness and muscle spasm. Heat should not be applied for more than 20 minutes at a time.

What best describes the manifestations of OA? a. Smaller joints are typically affected first. b. There is joint stiffness after periods of inactivity. c. Joint stiffness is accompanied by fatigue, anorexia, and weight loss. d. Pain and immobility may be aggravated by falling barometric pressure.

d. Pain and immobility of OA may be aggravated by falling barometric pressure. OA affects weight-bearing joints of knees and hips. Stiffness occurs on arising but usually subsides after 30 minutes. Pain during the day is relieved with rest. Fatigue, anorexia, and weight loss are nonspecific manifestations of the onset of RA.

15. Priority Decision: A patient who fell in the bathroom of the hospital room reports pain in the upper right arm and elbow. Which action should the nurse take first in managing a possible fracture before splinting the injury? a. Elevate the arm b. Apply ice to the site c. Notify the health care provider d. Perform a neurovascular check below the injury

d. Sensation, motor function, and pain distal to the injury should be checked before and after splinting to assess for nerve damage. Document results to avoid doubts about whether a problem discovered later was missed during the original examination or was caused by the treatment. Peripheral vascular assessment is needed and the HCP is notified. Elevation of the limb and application of ice should be instituted after the extremity is splinted.

Laboratory findings that the nurse would expect to be present in the patient with RA include a. polycythemia. b. increased immunoglobulin G (IgG). c. decreased white blood cell (WBC) count. d. antibodies to citrullinated peptide (anti-CCP).

d. The antibody to citrullinated peptide (anti-CCP) is more specific than RF for RA and may allow for earlier and more accurate diagnosis. Other tests include C-reactive protein (CRP) that is elevated from inflammatory reactions of RA, a finding that is useful in monitoring the response to therapy. Anemia, rather than polycythemia, is common, and immunoglobulin G (IgG) levels are normal. The white blood cell (WBC) count may be increased in response to inflammation and is also elevated in synovial fluid.

27. An older adult woman is admitted to the ED after falling at home. The nurse cautions her not to put weight on the leg after finding what in the patient assessment? a. Inability to move the toes and ankle b. Edema of the thigh extending to the knee c. Internal rotation of the leg with groin pain d. Shortening and external rotation of the leg

d. The classic signs of a hip fracture are external rotation and shortening of the leg accompanied by severe pain at the fracture site. Additional injury could be caused by weight bearing on the extremity. The patient may not be able to move the hip or the knee, but movement in the ankle and toes is not affected.

A patient is seen at the outpatient clinic for a sudden onset of inflammation and severe pain in the great toe. A definitive diagnosis of gouty arthritis is made on the basis of what? a. A family history of gout b. Elevated urine uric acid levels c. Elevated serum uric acid levels d. Presence of monosodium urate crystals in synovial fluid

d. The definitive diagnosis of gout is established by finding needle-like monosodium urate crystals in the synovial fluid of an inflamed joint or tophus. Although there is a familial predisposition to hyperuricemia, both environmental and genetic factors contribute to gout. Hyperuricemia and elevated urine uric acid are not diagnostic for gout because they may be related to a variety of drugs or may exist as a totally asymptomatic abnormality in the general population.

One important nursing intervention for the patient with fibromyalgia is to teach the patient to do what? a. Rest the muscles as much as possible to avoid triggering pain. b. Plan nighttime sleep and naps to obtain 12 to 14 hours of sleep a day. c. Try the use of food supplements such as glucosamine and chondroitin for relief of pain. d. Use techniques such as biofeedback, meditation, or cognitive behavioral therapy to manage stress.

d. The pain and related symptoms of fibromyalgia cause significant stress, and anxiety is a common finding. Stress management is an important part of the treatment and may include any of the commonly used relaxation strategies as well as psychologic counseling.

What is most likely to cause the pain experienced in the later stages of OA? a. Crepitation b. Bouchard's nodes c. Heberden's nodes d. Bone surfaces rubbing together

d. The pain in later OA is caused by bone surfaces rubbing together after the articular cartilage has deteriorated. Crepitation occurs earlier in the disease with loose particles of cartilage in the joint cavity. Bouchard's nodes and Heberden's nodes are tender but occur as joint space decreases and as early as 40 years of age.

43. Priority Decision: After change-of-shift handoff, which patient should the nurse assess first? a. A 58-year-old male reporting phantom pain and requesting an analgesic b. A 72-year-old male being transferred to a skilled nursing unit after repair of a hip fracture c. A 25-year-old female in left leg skeletal traction asking for the weights to be lifted for a few minutes d. A 68-year-old male with a new lower leg cast reporting the cast is too tight and he cannot feel his toes

d. The patient with a tight cast may be at risk for neurovascular compromise (impaired circulation and peripheral nerve damage) and should be assessed first. The other patients should be seen as soon as possible. Providing analgesia for the patient with phantom pain would be the next priority. The patient in skeletal traction needs explanation of the purpose and functioning of the traction. She may need analgesia or muscle relaxants to help tolerate the traction. Checking on the patient being transferred would include reassurance and paperwork completion.

A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse notifies the surgeon of possible early compartment syndrome when the patient experiences... a. increasing edema of the limb b. muscle spasms of the lower arm c. bounding pulse at the fracture site d. pain when passively extending the fingers

d. pain when passively extending the fingers Rationale: One or more of the following are characteristic of early compartment syndrome: (1) paresthesia (numbness and tingling sensation); (2) pain distal to the injury that is not relieved by opioid analgesics and is increased on passive stretch of muscle; (3) increased pressure in the compartment; and (4) pallor, coolness, and loss of normal color of the extremity. Paralysis (or loss of function) and pulselessness (or diminished or absent peripheral pulses) are late sign of compartment syndrome. The examination also includes assessment of peripheral edema, especially pitting edema, which may occur with severe injury.

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. the production of a variety of autoantibodies directed against components of the cell nucleus Rationale: Systemic lupus erythematosus (SLE) is marked by production of many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins. Autoimmune reactions (antinuclear antibodies [ANA]) are typically directed against constituents of the cell nucleus, especially DNA.

The nurse suspects an ankle sprain when a patient at the urgent care center describes... a. being hit by another soccer player during a game b. having ankle pain after sprinting around the track c. dropping a 10-lb weight on his lower leg at the health club d. twisting his ankle while running bases during a baseball game

d. twisting his ankle while running bases during a baseball game Rationale: A sprain is an injury to the ligaments surrounding a joint and is usually caused by a wrenching or twisting motion. Most sprains occur in the ankle and knee joints.