Chapter 38: Assessment and Management of Patients With Rheumatic Disorders

The nurse teaches the client that osteoarthritis is the most common and frequently disabling of joint disorders. affects young males. requires early treatment because most of the damage appears to occur early in the course of the disease. affects the cartilaginous joints of the spine and surrounding tissues.

is the most common and frequently disabling of joint disorders. Explanation: The functional impact of osteoarthritis on quality of life, especially for elderly clients, is often ignored. Reiter syndrome is a spondyloarthropathy that affects young adult males and is characterized primarily by urethritis, arthritis, and conjunctivitis. Psoriatic arthritis, characterized by synovitis, polyarthritis, and spondylitis, requires early treatment because of early damage caused by disease. Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues and is usually diagnosed in the second or third decade of life. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1104.

The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about? Methotrexate Celecoxib Methylprednisolone Mercaptopurine azathioprine

Methotrexate Explanation: Methotrexate is a DMARD that reduces the amount of joint damage and slows the damage to other tissues as well. Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID). Methylprednisolone is a steroid to reduce pain and inflammation and slow joint destruction. Mercaptopurine azathioprine is a cytotoxic drug. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Early Rheumatoid Arthritis, p. 1095.

The presence of crystals in synovial fluid obtained from arthrocentesis is indicative of gout. infection. inflammation. degeneration.

gout. Explanation: The presence of crystals is indicative of gout, whereas the presence of bacteria is indicative of infective arthritis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1108.

A client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse not say when teaching the client and family information about managing the disease? If you have problems with a medication, you may stop it until your next physician visit. Avoid sunlight and ultraviolet radiation. Pace activities. Maintain a well-balanced diet and increase fluid intake to raise energy levels and promote tissue healing.

If you have problems with a medication, you may stop it until your next physician visit. Explanation: Take medications exactly as directed and do not stop the medication if symptoms are relieved unless advised to do so by the physician. Sunlight tends to exacerbate the disease. Because fatigue is a major issue, allow for adequate rest, along with regular activity to promote mobility and prevent joint stiffness. Maintain a well-balanced diet and increase fluid intake to raise energy levels and promote tissue healing. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, p. 1180.

A client with degenerative joint disease asks the nurse for suggestions to avoid unusual stress on the joints. Which suggestion would be most appropriate? Keep shifting weight from one foot to the other. Perform aerobic exercises. Maintain complete bed rest. Maintain good posture.

Maintain good posture. Explanation: The nurse needs to remind the client with degenerative joint disease to maintain good posture. While the client need not maintain complete bed rest, performing aerobic exercises is not advisable as it may place undue stress on the joint worsening the condition. Shifting weight from one foot to the other does not help avoid unusual stress on a joint. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1107.

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

Celecoxib Explanation: The COX-2 inhibitor celecoxib (Celebrex) is associated with an increased risk of cardiovascular events, including myocardial infarction and stroke. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Table 38-3, p. 1088.

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

Scleroderma Explanation: Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. SLE is an immunoregulatory disturbance that results in increased autoantibody production. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1102.

A client is being placed on a purine-restricted diet. What foods will the nurse include in the client's diet plan? dairy products organ meats alcohol shellfish

dairy products Explanation: Purines are chemical compounds found in high concentrations in certain foods, particularly shellfish, organ meats, and some alcoholic beverages (e.g., beer, distilled liquors). Purines are implicated in gout. Another reason that clients with gout are advised to avoid alcohol is that alcohol of any kind may increase the free fatty acid concentrations that can exacerbate gout. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Nursing Management, p. 1108.

A client with rheumatoid arthritis (RA) is taking methotrexate. Which assessment findings indicate to the nurse that the client is experiencing side effects of this medication? Select all that apply. Hair loss Skin rash Weight gain Gastric distress Frequent infections

Hair loss Skin rash Gastric distress Frequent infections Methotrexate is considered an immunosuppressive agent. Side effects of this medication include alopecia (hair loss), skin rashes, gastrointestinal ulcerations, and increased infections. Weight gain is not identified as a side effect of methotrexate.

The nurse is planning teaching for a client with gout. Which topics will the nurse include in the teaching? Select all that apply. Weight loss Limiting exercise Decreasing alcohol intake Avoiding purine-rich foods Restricting the intake of water

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

A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include? tender to the touch reddened nonmovable located over bony prominence

located over bony prominence Explanation: Rheumatoid nodules usually are nontender, movable, and evident over bony prominences, such as the elbow or the base of the spine. The nodules are not reddened. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1094.

An older adult with rheumatoid arthritis limits going out with others because of the need to use a cane. Which response will the nurse make to this client? "It must be hard to get older." "Everyone will get older at some time." "Invite people over to your home instead." "Look at the cane as maintaining your independence."

"Look at the cane as maintaining your independence." Explanation: The body image and self-esteem of the older adult with rheumatic disease, combined with underlying depression, may interfere with the use of assistive devices such as canes. The use of adaptive equipment may be viewed by the older adult as evidence of aging rather than as a means of increasing independence. The nurse should focus on the cane as a method to increase independence rather than a sign of approaching old age. Reminding the client of aging are inappropriate responses. Inviting people to visit will not help improve the client's feelings about needing to use a cane for safe ambulation.

A client is being treated for hyperuricemia. Part of the treatment strategy is for the client to avoid contributing factors whenever possible. Which activities might bring on an acute attack? eating organ meats and sardines frequently drinking coffee high carbohydrate intake frequently ingesting salicylates

eating organ meats and sardines Explanation: During an acute attack, high-purine foods are avoided, including organ meats, gravies, meat extracts, anchovies, herring, mackerel, sardines, and scallops. The other listed factors do not worsen attacks. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, p. 1108.

The nurse is teaching a newly diagnosed client about systemic lupus erythematosus(SLE). What statement by the client indicates the teaching was successful? "This disorder is more common in men in their thirties and forties than in women." "The belief is that it is an autoimmune disorder with an unknown trigger." "SLE has very specific manifestations that make diagnosis relatively easy." "The symptoms are primarily localized to the skin but may involve the joints."

"The belief is that it is an autoimmune disorder with an unknown trigger." Explanation: Systemic lupus erythematosus is believed to be an autoimmune disorder but the triggering mechanism is not known. The disorder is more common in women than in men, most with the disorder in the 3rd or 4th decade of life. The disease is considered the "great imitator" because the clinical signs resemble many other conditions. SLE is a diffuse connective tissue disease that affects multiple body systems. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Pathophysiology, p. 1098.

The nurse is caring for a client who has been diagnosed with a "rheumatic disease." What nursing diagnoses will most likely apply to this client's care? Select all that apply. Fatigue Pain Alteration of self-concept Fluid and electrolyte imbalance Fluid volume deficit

Fatigue Pain Alteration of self-concept Clients with rheumatic diseases, which typically involve joints and muscles, experience problems with mobility, fatigue, and pain. Because of the limitations of the disease, clients often have an altered self-image and self-concept. Fluid and electrolyte imbalances are not typically associated with these types of diseases. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1082.

A client with rheumatoid arthritis reports disrupted sleep because of pain and stiffness. Which recommendations will the nurse make to help the client achieve restful sleep? Select all that apply. Use relaxation exercises. Establish a set time to sleep every night. Avoid caffeine before bedtime. Create a quiet sleep environment. Take pain medications four hours before sleep.

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

A nurse is assessing a client with possible osteoarthritis. What is the most significant risk factor for primary osteoarthritis? congenital deformity age trauma obesity

age Explanation: Age is the most significant risk factor for developing primary osteoarthritis. Development of primary osteoarthritis is influenced by genetic, metabolic, mechanical, and chemical factors. Secondary osteoarthritis usually has identifiable precipitating events such as trauma. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Osteoarthritis (Degenerative Joint Disease), p. 1104.

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? Providing comprehensive client teaching; including symptoms of the disorder, treatment options, and expected outcomes Administering ordered analgesics and monitoring their effects Performing meticulous skin care Supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware

Administering ordered analgesics and monitoring their effects Explanation: An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management her priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions don't not take priority over pain management. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1095.

The nurse is caring for a client with ankylosing spondylitis. Which educational information will the nurse provide to this client? Use of analgesics Use of laxatives Use of cough supressants Use of diuretics

Use of analgesics Explanation: Ankylosing spondylitis (AS) is a chronic inflammatory disease of the spine. Back pain is the characteristic feature. AS affects the cartilaginous joints of the spine and surrounding tissues, making them rigid, decreasing mobility, and leading to kyphosis or a stooped position. Constipation, chronic cough, and peripheral edema are not symptoms associated with AS.

Which of the following refers to fixation of a joint? Ankylosis Synovitis Pannus Articulations

Ankylosis Explanation: Fixation of a joint, called ankylosis, eliminates friction, but at the drastic cost of immobility. Inflammation is manifested in the joints as synovitis. Pannus has a destructive effect on the adjacent cartilage and bone. Articulations are joints. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1107.

The nurse is assessing a client with a history of ankylosing spondylitis. What will the nurse most commonly assess? low back pain increased urine output red, butterfly-shaped facial rash patchy hair loss on the scalp

low back pain Explanation: The most common symptoms of ankylosing spondylitis are low back pain and stiffness. A red, butterfly-shaped rash on the face and a patchy loss of hair are associated with systemic lupus erythematosus. Ankylosing spondylitis does not affect urine output. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Ankylosing Spondylitis, p. 1106.

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

Assess diet and activity at home Explanation: Clients with gout need to be educated about dietary restrictions in order to prevent repeated attacks. Foods high in purine need to be avoided, and alcohol intake has to be limited. Stressful activities should also be avoided. The nurse should assess to determine what is stimulating the repeated attacks of gout. The other interventions are not appropriate for a client with this problem. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1108.

A client with rheumatoid arthritis is prescribed a tumor necrosis factor (TNF)-alpha inhibitor. What medication might be prescribed? Etanercept Diclofenac Indomethacin Celecoxib

Etanercept Explanation: Etanercept is an example of a tumor necrosis factor (TNF)-alpha inhibitor used to treat rheumatoid arthritis. Diclofenac and indomethacin are nonsteroidal anti-inflammatory drugs (NSAIDs). Celecoxib is a cyclooxygenase-2 (COX-2) inhibitor. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Table 38-3, p. 1089.

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

Facial erythema, pericarditis, pleuritis, fever, and weight loss Explanation: An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1098.

A client was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. What would not be a part of teaching plan for this condition? applications of ice encouraging the client to eat a healthy diet avoiding caffeine and alcohol regular exercise and stress reduction

applications of ice Explanation: Application of ice is not part of the treatment regimen. Encouraging the client to eat a healthy diet, avoiding caffeine and alcohol, regular exercise, and stress reduction are part of the teaching plan. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, p. 1109.

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

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

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

aspirin Explanation: Salicylates like aspirin may have side effects such as tinnitus, gastric intolerance and bleeding. While celecoxib, methotrexate, and hydroxychloroquine have GI upset effects, the tinnitus is unique to aspirin. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Table 38-3, p. 1088.

The nurse is teaching a client about the characteristics of osteoarthritis. The nurse determines the client teaching was successful when the client states that which of the following may occur with osteoarthritis? Clients may have swan neck deformity. Clients may develop Heberden nodes. Clients will develop boutonniere deformity. Clients will have an ulnar deviation.

Clients may develop Heberden nodes. Explanation: Heberden nodes are a characteristic finding of osteoarthritis. Swan neck deformity, boutonniere deformity, and ulnar deviation are characteristic of rheumatoid arthritis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1094.

The nurse is assessing a patient with a diagnosis of scleroderma. What clinical manifestations of scleroderma does the nurse assess? (Select all that apply.) Decreased ventilation owing to lung scarring Dysphagia owing to hardening of the esophagus Dyspnea owing to fibrotic cardiac tissue Productive cough Butterfly-shaped rash on the face

Decreased ventilation owing to lung scarring Dysphagia owing to hardening of the esophagus Dyspnea owing to fibrotic cardiac tissue The changes within the body, although not visible directly, are vastly more important than the visible changes. The left ventricle of the heart is involved, resulting in heart failure. The esophagus hardens, interfering with swallowing. The lungs become scarred, impeding respiration. Digestive disturbances occur because of hardening (sclerosing) of the intestinal mucosa. Progressive kidney failure may occur. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1102.

A client with fibromyalgia is hesitant to talk about the symptoms. Which statement will the nurse make to help support the client? "Tell me what you've been experiencing." "Every client I talk with has similar symptoms." "Odd pain responses occur as a normal part of aging." "Most treatments for your kind of pain are not effective."

"Tell me what you've been experiencing." Explanation: Clients with fibromyalgia have endured their symptoms for a long period of time. They may feel as if their symptoms have not been taken seriously. Nurses need to pay special attention to supporting these clients and providing encouragement as they begin their program of therapy. Support groups may be helpful. Careful listening to clients' descriptions of their concerns and symptoms is essential to help them make the changes that are necessary to improve their quality of life. Because of this, the nurse should ask what the client has been experiencing. Saying that every client has similar symptoms, odd pain responses are a normal part of aging, and treatments for fibromyalgia pain being ineffective are not therapeutic and will not support the client.

A client with gout has been advised to lose weight. The client informs the nurse of plans to go on a "guaranteed rapid weight loss" plan that involves fasting and heavy exercise. Which response would be most appropriate? "The fasting is okay, but make sure you drink fluids when exercising." "Make sure to eat some fat occasionally with all that exercise." "Try combining the fasting with moderate exercise." "There might be some difficulties with your plan and fasting."

"There might be some difficulties with your plan and fasting." Explanation: Clients should avoid fasting, low-carbohydrate diets, and rapid weight loss because these measures increase the likelihood of ketone formation, which inhibits uric acid excretion. Gradual weight loss helps reduce serum uric acid levels in clients with gout. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Nursing Management, p. 1108.

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included? The time of day when exercise is performed isn't important. Exercising in the evening before going to bed is beneficial. Exercising immediately upon awakening allows the client to participate in activities when he has the greatest amount of energy. Delaying exercise for at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided.

Delaying exercise for at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided. Explanation: A client with osteoarthritis has increased stiffness in the morning upon awakening. Exercise should be scheduled at least 1 hour after awakening. Exercising in the evening interferes with the client's ability to rest at bedtime. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1105.

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

strategies for remaining active Explanation: The goals of osteoarthritis disease management are to decrease pain and stiffness and improve joint mobility. Strategies for remaining active are the most important client focus. The detection of complications, disease-modifying antirheumatic drugs management, and prevention of joint deformity are considerations, but not the most important priorities for the client. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1105.

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

Systemic lupus erythematosus (SLE) Explanation: SLE is an immunoregulatory disturbance that results in increased autoantibody production. Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Pathophysiology, p. 1098.

Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia all have the same type of symptoms. rarely respond to treatment. will eventually lose their ability to walk. may feel as if their symptoms are not taken seriously.

may feel as if their symptoms are not taken seriously. Explanation: Because clients present with widespread symptoms that are often vague in nature, health care providers may misdiagnose them. Clients feel as though people are not listening to them. Nurses need to provide support and encouragement. Symptoms of disease vary from client to client and respond to different treatments. Clients do not lose their ability to walk. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1109.

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

is the most common and frequently disabling of joint disorders. Explanation: The functional impact of osteoarthritis on quality of life, especially for elderly clients, is often ignored. Reiter syndrome is a spondyloarthropathy that affects young adult males and is characterized primarily by urethritis, arthritis, and conjunctivitis. Psoriatic arthritis, characterized by synovitis, polyarthritis, and spondylitis, requires early treatment because of early damage caused by disease. Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues, making them rigid and decreasing mobility; it is usually diagnosed in the second or third decade of life. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1104.

A client asks the nurse how their rheumatoid arthritis is diagnosed. The nurse knows that which finding from diagnostic tests can be used to diagnose rheumatoid arthritis? Boney erosions on x-ray Reduced muscle mass on CT scan Evidence of healed fractures on MRI Atherosclerotic plaques on an arteriogram

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

The nurse intervenes to assist the client with fibromyalgia to cope with which symptoms? Chronic fatigue, generalized muscle aching, and stiffness Pain, viral infection, and tremors Diminished vision, chronic fatigue, and reduced appetite Generalized muscle aching, mood swings, and loss of balance

Chronic fatigue, generalized muscle aching, and stiffness Explanation: Fibromyalgia is a common condition that involves chronic fatigue, generalized muscle aching, and stiffness. The cause is unknown, and no pathologic characteristics specific for the condition have been identified. Treatment consists of attention to the specific symptoms reported by the client. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants are used to improve or restore normal sleep patterns, and individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in these individuals. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1109.

A client with rheumatoid arthritis is concerned because the appearance of the hands is changing. Which hand deformities will the nurse expect to assess in this client? Select all that apply. Swan neck Ulnar deviation Heberden's nodes Bouchard's nodes Enlarged knuckles

Swan neck Ulnar deviation Deformities of the hands is common in RA and includes swan neck deformities and ulnar deviation. The deformity may be caused by misalignment resulting from swelling, progressive joint destruction, or the subluxation (partial dislocation) that occurs when one bone slips over another and eliminates the joint space. Deformities of RA differ from those seen with osteoarthritis (OA), such as Heberden's and Bouchard's nodes. Enlarged knuckles are not associated with either condition.

The client with an inflamed knee scheduled to have an arthrocentesis asks the nurse what the synovial fluid will look like. What is the best response by the nurse? The fluid will be clear and pale. The fluid will be milky, cloudy, and dark yellow. The amount of fluid will be scant in volume. The fluid will be straw colored.

The fluid will be milky, cloudy, and dark yellow. Explanation: An arthrocentesis shows abnormal synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Assessment and Diagnostic Findings, p. 1095.

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

celecoxib Explanation: The cyclooxygenase-2 inhibitors, such as celecoxib, have been shown to inhibit inflammatory processes but do not inhibit the protective prostaglandin synthesis in the gastrointestinal (GI) tract. Therefore, patients who are at increased risk for gastrointestinal complications, especially GI bleeding, have been managed effectively with celecoxib. Ibuprofen, methotrexate, and sulfasalazine may cause GI irritation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Table 38-3, p. 1088.

The nurse is reviewing the medication administration record of the client. Which medication would lead the nurse to suspect that the client is suffering from an acute attack of gout? penicillamine methotrexate prednisone colchicine

colchicine Explanation: Colchicine is prescribed for the treatment of an acute attack of gout. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1108.

The nurse is gathering a health history for a client with osteoarthritis. What clinical manifestation will the nurse expect to find? small joint involvement joint pain that increases with rest subcutaneous nodules early morning stiffness

early morning stiffness Explanation: Osteoarthritis is characterized by early morning stiffness that decreases with activity. Large joints are usually involved with osteoarthritis. Joint pain is a constant with osteoarthritis. Clients with rheumatoid arthritis have subcutaneous nodules. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1105.

The nurse is assessing a client with primary Sjogren's syndrome. Which interventions will the nurse add to this client's plan of care? Select all that apply. Analgesics for pain management Education on proper sleep practices Use of artificial tears Increased fluid intake Provide a high fiber diet

Analgesics for pain management Education on proper sleep practices Use of artificial tears Increased fluid intake Primary Sjögren's syndrome is a rare systemic autoimmune disease that predominantly affects middle-aged women. The most common symptoms include pain, fatigue, kerotoconjunctivitis sicca or dry eyes, and xerostomia or dry mouth. Constipation is not commonly identified as a symptom of primary Sjogren's syndrome.

The nurse is teaching a client about the characteristics of osteoarthritis. How will the nurse determine the client teaching was successful? Clients may have swan neck deformity. Clients may develop Heberden nodes. Clients will develop boutonniere deformity. Clients will have an ulnar deviation.

Clients may develop Heberden nodes. Explanation: Heberden nodes are a characteristic finding of osteoarthritis. Swan neck deformity, boutonniere deformity, and ulnar deviation are characteristic of rheumatoid arthritis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1094.

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis? "My legs feel weak." "My finger joints are oddly shaped." "I have pain in my hands." "I have trouble with my balance."

"My finger joints are oddly shaped." Explanation: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Assessment and Diagnostic Findings, p. 1094.

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine positivity for the disorder. Which statement by the nurse is most accurate? "You should discuss that matter with your health care provider." "The diagnosis won't be based on the findings of a single test but by combining all data found." "SLE is a very serious systemic disorder." "Tell me more about your concerns about this potential diagnosis."

"The diagnosis won't be based on the findings of a single test but by combining all data found." Explanation: There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the health care provider, stating that SLE is a serious systemic disorder, and asking the client to express feelings about the potential diagnosis do not answer the client's question. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Assessment and Diagnostic Findings, p. 1099.

An older adult with rheumatoid arthritis says exercise was not effective. Which response will the nurse make to learn the reason for the failure of this treatment approach? "Does exercise usually work for you?" "Why do you think the exercise didn't work?" "Do you think you are too old to exercise?" "What types of exercise were you doing?"

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

A client with rheumatoid arthritis asks what can be used to control pain besides taking pain medication. Which recommendations will the nurse suggest to this client? Select all that apply. Splints Warm tub bath Assistive walking devices Warm moist compresses Transcutaneous nerve stimulator

Splints Warm tub bath Assistive walking devices Warm moist compresses Nonpharmacologic pain management approaches have been helpful to reduce the discomfort of rheumatoid arthritis. These approaches include splints to support the affected joint and reduce spasms. Superficial heat application through warm tub baths and moist compresses help relieve pain, stiffness, and muscle spasms. Assistive devices for ambulation ease pain by limiting movement or stress from putting weight on painful joints. Transcutaneous nerve stimulator is not identified as a method to reduce the discomfort of rheumatoid arthritis.

A client with rheumatoid arthritis (RA) is being evaluated for medication therapy. Which testing will the nurse anticipate the client will need before medications are started? Select all that apply. Serum electrolytes Liver function tests Tuberculin skin test Testing for hepatitis B Testing for hepatitis C

Liver function tests Tuberculin skin test Testing for hepatitis B Testing for hepatitis C Liver function tests are recommended for most disease-modifying antirheumatic drugs (DMARD) because it can cause elevation of the liver enzymes. A tuberculin (TB) skin test should be done prior to the initiation of certain medications to rule out tuberculosis. In the event the client has latent TB and has never been treated, the infection can be reactivated. The client should also be assessed for hepatitis B and hepatitis C, which could impact treatment strategies if positive. If the client tests positive for hepatitis, the infection should be treated prior to starting medication. Serum electrolytes are not identified as being routinely done before beginning medication therapy for RA because it is not part of the pharmacological side effects or adverse effects of DMARDs.

A client with a history of gout experiences an attack every 2 to 3 months despite losing weight and stopping all alcohol intake. Which question will the nurse ask when assessing this client? "Are you taking the medication as prescribed?" "Have you reduced the amount of daily exercise?" "Have you increased your intake of fat-soluble vitamins?" "Are you taking frequent rest periods throughout the day?"

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

As part of the assessment process for a client suspected of having gout, the nurse evaluated the client's serum uric acid levels. Select the value that is considered above the saturation point for crystal formation. 3.2 mg/dL (0.19mmol/L) 4.0 mg/dL (0.24 mmol/L) 5.4 mg/dL (0.32 mmol/L) 6.8 mg/dL (0.40 mmol/L)

6.8 mg/dL (0.40 mmol/L) Explanation: Hyperuricemia, a serum uric acid concentration above 6.8 mg/dL (0.40 mol/L) can cause urate crystal deposition which can lead to gout. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Gout: Pathophysiology, p. 1107.

A client with fibromyalgia asks why physical therapy has been prescribed. Which response will the nurse make? "It will take your mind off your health problem." "I will ask the health care provider it if is necessary." "It is used instead of prescribing medications for the condition." "It will help with the overall deconditioning that has occurred."

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

Which client is most likely to develop systemic lupus erythematosus (SLE)? A 25-year-old White male A 25-year-old Jewish female A 27-year-old Black female A 35-year-old Hispanic male

A 27-year-old Black female Explanation: SLE strikes nearly 10 times as many women as men and is most common in women between ages 15 and 40. SLE affects more Black women than white women; its incidence is about 1 in every 250 Black women, compared to 1 in every 700 white women. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Pathophysiology, p. 1098.

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

Degenerative joint disease Explanation: Obesity predisposes the client to degenerative joint disease. Obesity isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Osteoarthritis (Degenerative Joint Disease), p. 1104.

Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)? Nonsteroidal anti-inflammatory drugs (NSAIDs) Disease-modifying antirheumatic drugs (DMARDs) Tumor necrosis factor (TNF) blockers Glucocorticoids

Disease-modifying antirheumatic drugs (DMARDs) Explanation: Once a diagnosis of RA has been made, treatment should begin with DMARDs. NSAIDs are used for pain and inflammation relief but must be used with caution in long-term chronic diseases due to the possibility of gastric ulcers. TNF blockers interfere with the action of tumor necrosis factor (TNF). Oral glucocorticoids, such as prednisone and prednisolone, are indicated for patients with generalized symptoms. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Early Rheumatoid Arthritis, p. 1095.

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find? Increased red blood cell count Increased C4 complement Elevated erythrocyte sedimentation rate Increased albumin levels

Elevated erythrocyte sedimentation rate Explanation: The erythrocyte sedimentation rate (ESR) may be elevated, particularly as the disease progresses. ESR shows inflammation associated with RA. Red blood cell count and C4 complement component are decreased. Serum protein electrophoresis may disclose increased levels of gamma and alpha globulin but decreased albumin. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1094.

The client with osteoarthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care? Reports ability to perform ADLs Reports decreased joint pain Shows increased joint flexibility Has a weight gain of 5 pounds

Has a weight gain of 5 pounds Explanation: Obesity is a risk factor for osteoarthritis. Excess weight is a stressor on the weight-bearing joints. Weight reduction is often a part of the therapeutic regimen. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Nursing Management, p. 1106.

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

Hypertension Explanation: Hypertension is suggestive of renal damage in the client with systemic lupus erythematous. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1099.

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

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

Which points should be included in the medication teaching plan for a client taking adalimumab? The medication is administered intramuscularly. The client should continue taking the medication if fever occurs. The medication is given at room temperature. It is important to monitor for injection site reactions.

It is important to monitor for injection site reactions. Explanation: It is important to monitor for injection site reactions when taking adalimumab. The medication is injected subcutaneously and must be refrigerated. The medication should be withheld if fever occurs. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Table 38-3, p. 1089.

A client has a serum study that is positive for the rheumatoid factor. What will the nurse tell the client about the significance of this test result? It is diagnostic for Sjögren's syndrome. It is diagnostic for systemic lupus erythematosus. It is specific for rheumatoid arthritis. It is suggestive of rheumatoid arthritis.

It is suggestive of rheumatoid arthritis. Explanation: Rheumatoid factor is present in about 70% to 80% of patients with rheumatoid arthritis, but its presence alone is not diagnostic of rheumatoid arthritis, and its absence does not rule out the diagnosis. The antinuclear antibody (ANA) test is used to diagnose Sjögren's syndrome and systemic lupus erythematosus. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1094, 1099.

Which of the following maybe the first and only physical sign of symptomatic osteoarthritis (OA)? Limited passive movement Joint enlargement Joint instability Limb shortening

Limited passive movement Explanation: Limited passive movement can be the first and only physical sign of symptomatic OA. Physical assessment of the musculoskeletal system reveals joint enlargement, joint instability, and limb shortening. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1105.

Which joint is most commonly affected in gout? Metatarsophalangeal Tarsal area Ankle Knee

Metatarsophalangeal Explanation: The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of clients); this is referred to as podagra. The wrists, fingers, and elbows are less commonly affected. The tarsal area, ankle, and knee are not the most commonly affected in gout. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1108.

Which condition is the leading cause of disability and pain in the elderly? Osteoarthritis (OA) Rheumatoid arthritis (RA) Systemic lupus erythematous (SLE) Scleroderma

Osteoarthritis (OA) Explanation: OA is the leading cause of disability and pain in the elderly. RA, SLE, and scleroderma are not leading causes of disability and pain in the elderly. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1104.

What intervention is a priority for a client diagnosed with osteoarthritis? Physical therapy and exercise Hydrotherapy Colchicine Allopurinol

Physical therapy and exercise Explanation: Clients with osteoarthritis need to maintain joint mobility. To preserve joint function, individuals need to learn appropriate activities. Colchicine and allopurinol are used for gout, not osteoarthritis. Hydrotherapy is not a priority for care. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1106.

A client with systemic lupus erythematosus is prescribed belimumab. For which reason will the nurse question giving the client this medication? Report of constipation Discoid rash present over the face Bilateral knee joint swelling is present Received a live vaccination a week ago

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

The nurse is caring for a client with palindromic rheumatism. The nurse knows that this type of rheumatism can lead to which diagnosis? Scleroderma Fibromyalgia Rheumatoid arthritis Systemic lupus erythematosus

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

The nurse is performing discharge teaching for a client with rheumatoid arthritis. What teachings are priorities for the client? Select all that apply. Safe exercise Narcotic safety Medication dosages and side effects Dressing changes Assistive devices

Safe exercise Medication dosages and side effects Assistive devices The client with rheumatoid arthritis who is being discharged to home needs information on how to exercise safely to maintain joint mobility. Medication doses and side effects are always an essential part of discharge teaching. Assistive devices, such as splints, walkers, and canes, may assist the client to perform safe self-care. Narcotics are not commonly used, and there would be no reason for dressings. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Chart 38-4, p. 1097.

A client with systemic lupus erythematosus (SLE) is prescribed hydroxychloroquine. Which teaching will the nurse include for this client? Exercise High-protein diet Smoking cessation Vitamin D supplements

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

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

Tophi Explanation: Tophi, when problematic, are surgically excised. Subchondral bone refers to a bony plate that supports the articular cartilage. Pannus refers to newly formed synovial tissue infiltrated with inflammatory cells. Joint effusion refers to the escape of fluid from the blood vessels or lymphatic vessels into the joint cavity. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1108.

Which drug is not used in the treatment of rheumatoid arthritis? allopurinol etanercept adalimumab methotrexate

allopurinol Explanation: Allopurinol is used in the treatment of gout. Etanercept, adalimumab, and methotrexate are all used in the treatment of rheumatoid arthritis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1095.

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

joint stiffness that increases with activity Explanation: A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that increases with activity and movement. Erythema and edema over the affected joint, anorexia, weight loss, and fever and malaise are associated with rheumatoid arthritis, a more severe and destructive form of arthritis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Pathophysiology, p. 1104.

The client asks the nurse about types of exercise that do not stress the joints. What exercise will the nurse include in the teaching plan? jogging running on a treadmill t'ai chi weight lifting

t'ai chi Explanation: T'ai chi is low impact, so this is the best exercise for low joint impact. Jogging, weight lifting, and running on a treadmill are high-impact, jarring types of exercise. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1105.

The nurse is constructing a teaching plan for the client newly diagnosed with scleroderma. What should the nurse include in the teaching plan? Take all antibiotics until they are gone. Perform weight-bearing exercises daily. Avoid sunlight and ultraviolet light. Protect the hands and feet from cold.

Protect the hands and feet from cold. Explanation: Raynaud's phenomenon is associated with scleroderma. Client teaching must include strategies for protecting the feet and hands. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1102.

A client with rheumatoid arthritis wants to participate in water aerobics classes for arthritis at the community center. Which statement will the nurse respond to this client? "Don't go if your joints are inflamed." "Be sure to wear nonslip footwear for safety." "That's not the best activity for misaligned joints." "Have someone check your blood pressure before exercising."

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

A client is experiencing painful joints and changes in the lungs, heart, and kidneys. For which condition will the nurse schedule this client for diagnostic tests? Heart disease Vascular diseases Metabolic disorders Autoimmune disorders

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

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

hydroxychloroquine Explanation: The DMARD hydroxychloroquine is associated with visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. The nurse should emphasize the need for ophthalmologic examinations every 6-12 months. Azathioprine, diclofenac, and cyclophosphamide do not have visual changes as a side effect. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Table 38-3, p. 1088.

The nurse is performing a health history with a new client in the clinic. What is the most common reason for a client to seek medical attention for arthritis? pain joint swelling stiffness weakness

pain Explanation: The symptom that most commonly causes a person to seek medical attention is pain. Other common symptoms include joint swelling, limited movement, stiffness, weakness, and fatigue. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Introduction, p. 1082.

The nurse is performing a health history with a new client with fibromyalgia. What will the nurse expect to assess as the mostcommon finding associated with fibromyalgia? Heberden nodes jaw locking widespread chronic pain butterfly facial rash

widespread chronic pain Explanation: The most common finding associated with fibromyalgia is widespread and chronic pain. Heberden nodes are associated with osteoarthritis. Jaw locking is a manifestation of temporomandibular joint dislocation. A butterfly facial rash is associated with systemic lupus erythematosus. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Assessment Findings, p. 1176.

The nurse is caring for a client with systemic lupus erythematosus (SLE). Which interventions will the nurse incorporate into this client's plan of care? Select all that apply. Antipyretic medications for fever Monitoring for jaundice Providing high fiber diet for diarrhea Providing analgesics for joint pain Monitoring for rash to the skin

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

A patient is hospitalized with a severe case of gout. The patient has gross swelling of the large toe and rates pain a 10 out of 10. With a diagnosis of gout, what should the laboratory results reveal? Glucosuria Hyperuricemia Hyperproteinuria Ketonuria

Hyperuricemia Explanation: Gout is caused by hyperuricemia (increased serum uric acid). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Pathophysiology, p. 1107.

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

Encourage weight loss and an increase in aerobic activity Explanation: Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening, are important approaches to pain management. Clients should be assisted to plan their daily exercise at a time when the pain is least severe, or plan to use an analgesic, if appropriate, before an exercise session. Gastrointestinal complications, especially bleeding, are associated with the use of nonsteroidal anti-inflammatory drugs. Topical analgesics such as capsaicin and methyl salicylate may be used for pain management. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1106.

The nurse is caring for a client with ankylosing spondylitis (AS). Which medication will the nurse expect to be prescribed for this client? Antibiotics Anticoagulants Oral corticosteroids Nonsteroidal anti-inflammatory drugs (NSAIDs)

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

A client is diagnosed with psoriatic arthritis. In which areas will the nurse expect the client to experience pain? Select all that apply. Scapula Intercostals Plantar fascia Achilles tendon Tibial tuberosities

Plantar fascia Achilles tendon Tibial tuberosities Psoriatic arthritis is characterized by synovitis, polyarthritis, and spondylitis. Inflammatory back pain is a common symptom. Other sites of pain commonly seen in these clients are the plantar fascia, Achilles tendon, or tibial tuberosity areas. Pain in these areas is common from the inflammation that occurs at the entheses, where tendons and ligaments attach to the bone. Pain in the scapula and intercostals is not associated with psoriatic arthritis.

A patient is suspected of having myositis. The nurse prepares the patient for what procedure that will confirm the diagnosis? Bone scan Computed tomography (CT) Magnetic resonance imaging (MRI) Muscle biopsy

Muscle biopsy Explanation: As with other diffuse connective tissue disorders, no single test confirms polymyositis. An electromyogram is performed to rule out degenerative muscle disease. A muscle biopsy may reveal inflammatory infiltrate in the tissue. Serum studies indicate increased muscle enzyme activity. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Assessment and Diagnostic Findings, p. 1103.

A client is recovering from an attack of gout. What will the nurse include in the client teaching? Weight loss will reduce purine levels. Weight loss will reduce inflammation. Weight loss will increase uric acid levels and reduce stress on joints. Weight loss will reduce uric acid levels and reduce stress on joints.

Weight loss will reduce uric acid levels and reduce stress on joints. Explanation: Weight loss will reduce uric acid levels and reduce stress on joints. Weight loss will not reduce purine levels, reduce inflammation, or increase uric acid levels. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1108.

Which of the following would the nurse expect to assess as the most common finding associated with fibromyalgia? Heberden's nodes Jaw locking Widespread chronic pain Butterfly facial rash

Widespread chronic pain Explanation: The most common finding associated with fibromyalgia is widespread and chronic pain, as clients experience an increased sensitivity to pain signals. Heberden's nodes are associated with osteoarthritis. Jaw locking is a manifestation of temporomandibular joint dislocation. A butterfly facial rash is associated with systemic lupus erythematosus. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Fibromyalgia, p. 1109.

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

gouty arthritis Explanation: Gout results from the inability to metabolize purines. This condition is most commonly seen in men and usually affects the legs, feet, and knees. Osteoarthritis is caused by degeneration of the joints. Rheumatoid arthritis is a systemic disorder more common in women of childbearing age. Reactive arthritis is seen with infections and is most common in young adult males. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1108.

A client with rheumatoid arthritis has experienced increasing pain and progressing inflammation of the hands and feet. What would be the expected goal of the likely prescribed treatment regimen? minimizing damage eradicating pain eliminating deformities promoting sleep

minimizing damage Explanation: Although RA cannot be cured, much can be done to minimize damage. Treatment goals include decreasing joint inflammation before bony ankylosis occurs, relieving discomfort, preventing or correcting deformities, and maintaining or restoring function of affected structures. Early treatment leads to the best results. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, p. 1095.

A client arrives at the orthopedic clinic and reports suspecting astress fracture of the right foot. The physician orders an x-ray with negative results. What does the nurse understand that these negative results can mean? fluid intake protein-rich foods purine-rich foods carbohydrates

purine-rich foods Explanation: Clients with gout should be advised to have adequate protein with the limitation of purine-rich foods to avoid contributing to the underlying problem. The diet should also be relatively high in carbohydrates and low in fats because carbohydrates increase urate excretion and fats retard it. A high fluid intake is recommended because it helps increase the excretion of uric acid. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1108.

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

colchicine Explanation: The treatment of gout involves managing the acute inflammatory stage, preventing flare-ups, and controlling hyperuricemia. Colchicine, along with indomethacin, ibuprofen, or a corticosteroid, is prescribed to relieve an acute attack of gout. Probenecid and anturane increase the urinary excretion of uric acid, and allopurinol breaks down purines before uric acid is formed. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Medical Management, p. 1108.

The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care? ability to perform activities of daily living (ADL) decreased joint pain increased fatigue a weight gain of 2 pounds

increased fatigue Explanation: Fatigue is common with rheumatoid arthritis. Finding a balance between activity and rest is an essential part of the therapeutic regimen. The client is reporting being able to do ADLs and decreased joint pain. The client's weight gain of 2 pounds does not correlate with self-care problems. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Educating Patients About Self-Care, p. 1097.

The nurse is caring for a client with rheumatoid arthritis who suffers with chronic pain in the hands. When would be the best time for the nurse to perform range-of-motion exercises? First thing in the morning when the client wakes After cool compresses have been applied to the hands After the client has had a warm paraffin hand bath After the client has a diagnostic test

After the client has had a warm paraffin hand bath Explanation: Whether resting or moving, clients in this stage of the disease have considerable chronic pain, which typically is worse in the morning after a night's rest. Warmth helps decrease the symptoms of pain and will be the best time to perform range of motion exercises.

A health care provider orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis? Increased total serum complement levels Negative antinuclear antibody test Negative lupus erythematosus cell test An above-normal anti-deoxyribonucleic acid (DNA) test

An above-normal anti-deoxyribonucleic acid (DNA) test Explanation: Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Assessment and Diagnostic Findings, p. 1099.

A client with a discoid facial rash caused by systemic lupus erythematosus (SLE) asks why a urine sample is needed. Which response will the nurse make to the client? "It is a routine test done on everyone." "The lupus can affect your kidney function." "The medication you take can affect your bladder." "The test will determine how long you will have the rash."

"The lupus can affect your kidney function." Explanation: Nephritis as a result of SLE, also referred to as lupus nephritis, occurs due to a buildup of antibodies and immune complexes that cause damage to the nephrons. Early detection allows for prompt treatment so that renal damage can be prevented. Serum creatinine levels and urinalysis are used in screening for renal involvement. Urinalysis is not a routine test done on every client. The urinalysis is not being used to determine if the client's medication is affecting the bladder. The urinalysis will not determine the length of time the client will have the rash.

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

"Pace yourself and rest frequently, especially after activities." Explanation: A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace oneself during daily activities. Telling the client to do chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace oneself and take frequent rests rather than doing all chores at once. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Nursing Management, p. 1106.