Chapter 65: Nursing Management - Arthritis and Connective Tissue Diseases

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? a. "Infertility can result from the medications used to control your disease." b. "Pregnancy will result in a temporary remission of your signs and symptoms." 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 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.

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)? a. Low-impact aerobic exercise b. Relaxation strategy (biofeedback) c. Antiseizure drug pregabalin (Lyrica) d. Morphine sulfate extended-release tablets e. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

A, B, C, E 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)? a. Nodules present b. Consistent muscle strength c. Localized disease symptoms d. No destructive changes on x-ray e. Subluxation of joints without fibrous ankylosis

A, E 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.

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

B 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 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? 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 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.

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? 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 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.

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

C 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 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? a. Limit fluid intake. b. Administration of probenecid (Benemid) c. Administration of allopurinol (Zyloprim) d. Administration of nonsteroidal antiinflammatory drugs (NSAIDs)

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

Correct answer: a Rationale: Patients with ankylosing spondylitis (AS) should exercise after pain and stiffness are managed. Postural control is important for minimizing spinal deformity. The exercise regimen should include back, neck, and chest stretches. The nurse should educate the patient with AS about regular exercise and attention to posture, local moist-heat applications, and knowledgeable use of drugs. The nurse should discourage excessive physical exertion during periods of active flare-up of the disease. Proper positioning at rest is essential. The mattress should be firm, and the patient should sleep on their back with a flat pillow, avoiding positions that encourage flexion deformity. Postural training emphasizes avoiding spinal flexion (e.g., leaning over a desk), heavy lifting, and prolonged walking, standing, or sitting.

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

Correct answer: b Rationale: Heberden's nodes are bony deformities in the distal interphalangeal joints that are indicative of osteophyte formation and loss of joint space in osteoarthritis.

In teaching a patient with SLE about the disorder, the nurse knows that 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.

Correct answer: d Rationale: Systemic lupus erythematosus (SLE) is characterized by the 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 characteristically are directed against constituents of the cell nucleus (e.g., antinuclear antibodies [ANAs]), particularly DNA. Circulating immune complexes containing antibody against DNA are deposited in the basement membranes of capillaries in the kidneys, heart, skin, brain, and joints. Complement is activated, and inflammation occurs. The overaggressive antibody response is also related to activation of B and T cells. The specific manifestations of SLE depend on which cell types or organs are involved. SLE is a type III hypersensitivity response.

A patient with rheumatoid arthritis is experiencing articular involvement of the joints. The nurse recognizes that 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.

Correct answers: b, e 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.

Which patient statement most clearly suggests a need to assess the patient for ankylosing spondylitis (AS)? a. "My right elbow has become red and swollen over the last few days." b. "I wake up stiff every morning, and my knees just don't want to bend." c. "My husband tells me that my posture has become so stooped this winter." d. "My lower back pain seems to be getting worse all the time, and nothing seems to help."

D AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.

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

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

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? 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." d. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

D 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.

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

A 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 increase the risk for aspiration with interstitial lung disease in up to 65% of patients. The treatment of polymyositis starts with high-dose corticosteroids that cause immunosuppression. If this does not work, other immunosuppressive drugs may be used. Reactive arthritis (Reiter's syndrome) occurs with urethritis, conjunctivitis, and mucocutaneous lesions with the asymmetric arthritis involving large joints of the lower extremities and toes. This patient is not at increased risk for safety problems. Sjögren's syndrome decreases moisture produced by exocrine glands, especially in the mouth and eyes and is without increased risk of injury or interstitial lung involvement. Systemic lupus erythematosus (SLE) is a multisystem inflammatory autoimmune disorder treated with NSAIDs, antimalarial agents. Safety would not be an important issue early in the disease.

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? 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 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 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? 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 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 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? a. Ulnar drift b. Pain with joint movement c. Reddened, swollen affected joints d. Stiffness that increases with movement

B 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.

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? 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 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.

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 probably have a high chance of getting arthritis." c. "I'm hoping that surgery will be an option for me in the future." d. "I understand that I'm going to be vulnerable to getting infections."

C 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 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)? a. Calcinosis b. Weight loss c. Sclerodactyly d. Difficulty swallowing e. Weakened leg muscles

A, C, D 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.

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

Correct answer: b Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is administered 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).

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

Correct answer: c Rationale: Cyclosporine (Restasis) ophthalmic drops can be used to treat the chronic dry eye associated with Sjögren's syndrome.

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? a. Eggs b. Liver c. Salmon d. Chicken

A 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.