Honan-Chapter 39: Nursing Management: Patients With Rheumatic Disorders

The nurse has finished the receiving shift report at 7:30 AM. Which patient should the nurse assess first? A. The patient with scleroderma who had an episode of dyspnea during the night shift B. The patient diagnosed with OA who complains of morning joint stiffness C. The patient who needs to receive a scheduled 8 AM IV adrenal corticosteroid D. The patient suspected of an acute gout attack who is scheduled for an arthrocentesis

A. The patient with scleroderma who had an episode of dyspnea during the night shift RATIONALE The nurse must take a systematic approach and decide if any patient is experiencing a life-threatening or life-altering complication. Scleroderma can lead to cardiopulmonary involvement and complications. The nurse needs to pay attention to pulmonary or cardiac symptoms. Morning joint stiffness is an expected clinical manifestation. There is enough time to assess the patient with scleroderma before proceeding to the patient scheduled for 8 am. medication or arthrocentesis.

Which statement indicates the patient requires further teaching regarding the nutritional management of gout? A. "I need to limit my alcohol intake." B. "I need to avoid fad starvation diets." C. "I need to follow a high-protein diet." D. "I need to eliminate fructose drinks."

C. "I need to follow a high-protein diet." RATIONALE Many health care providers believe that a person with gout needs to avoid trigger foods: foods high in protein such as red meat, lamb and pork; foods high in purines such as organ meats and seafood especially shellfish; limit alcohol such as beer and grain liquors; avoid starvation diets; and avoid fructose drinks. Fructose breaks down into purines in the body that leads to uric acid formation and gout. It is also important to drink plenty of fluids.

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

D. Weight loss will reduce uric acid levels and reduce stress on joints. RATIONALE Weight loss will reduce uric acid levels and reduce stress on joints. Weight loss will not reduce purine levels, reduce inflammation, or increase uric acid levels.

A patient with SLE is admitted to the hospital for evaluation and management of acute joint inflammation. Which information obtained in the admission laboratory testing results is of most concern to the nurse? A. Elevated blood urea nitrogen (BUN) B. Increased C-reactive protein C. Positive ANA D. Positive RF

A. Elevated blood urea nitrogen (BUN) RATIONALE A patient with SLE is at risk for developing nephropathy, an elevation of blood urea nitrogen warrants further diagnostic testing of renal function. The other laboratory results are expected in patients with SLE.

The nursing educator is talking with a group of recent nursing graduates about common diagnoses on the unit. What diffuse connective tissue disease would the instructor tell the group is caused by an autoimmune reaction that results in phagocytosis, producing enzymes within the joint that break down collagen and cause edema? A. Rheumatoid arthritis (RA) B. Systemic lupus erythematosus (SLE) C. Osteoporosis D. Polymyositis

A. Rheumatoid arthritis (RA) RATIONALE In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately forms pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not result in phagocytosis.

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? A. Providing comprehensive client teaching; including symptoms of the disorder, treatment options, and expected outcomes B. Administering ordered analgesics and monitoring their effects C. Performing meticulous skin care D. 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 RATIONALE 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.

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? A. First thing in the morning when the client wakes B. After cool compresses have been applied to the hands C. After the client has had a warm paraffin hand bath D. After the client has a diagnostic test

C. After the client has had a warm paraffin hand bath RATIONALE 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.

When assessing a patient, the nurse knows that which clinical manifestations are shared by rheumatoid arthritis and OA? A. Joint space narrowing and a decreased C4 level B. Symmetrical knee involvement and joint effusions C. Tophi, joint enlargement, and severe pain D. Joint swelling, stiffness, and pain

D. Joint swelling, stiffness, and pain RATIONALE Joint swelling, stiffness, and pain are manifestations of rheumatoid arthritis (RA) and osteoarthritis (OA). Joint space narrowing is seen on x-ray in OA and RA, however, a decreased C4 level is found only in RA, an autoimmune disorder. Osteoarthritis typically affects joints asymmetrically, while RA typically affects symmetrical joints and more commonly results in effusions. Tophi are only found in patients with gout.

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

C. "Pace yourself and rest frequently, especially after activities." RATIONALE A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace oneself during daily activities. Telling the client to do chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace oneself and take frequent rests rather than doing all chores at once.

A 62-year-old male patient has been prescribed allopurinol (Zyloprim) for the treatment of gout. When providing health education to this patient about his new medication, the nurse should know that this drug achieves a therapeutic effect by: A. Interrupting the breakdown of purines B. Increasing renal excretion of uric acid C. Buffering the presence of uric acid in joints D. Inhibiting the inflammatory process

A. Interrupting the breakdown of purines RATIONALE Allopurinol is a xanthine oxidase inhibitor that interrupts the breakdown of purines before uric acid is formed. It does not directly influence renal function or the inflammatory process.

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

A. joint stiffness that decreases with activity RATIONALE A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that decreases 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.

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

B. "The diagnosis won't be based on the findings of a single test but by combining all data found." RATIONALE There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the health care provider, stating that SLE is a serious systemic disorder, and asking the client to express feelings about the potential diagnosis do not answer the client's question.

Which of the following procedures involves a surgical fusion of the joint? A. Arthrodesis B. Synovectomy C. Tenorrhaphy D. Osteotomy

A. Arthrodesis RATIONALE An arthrodesis is a surgical fusion of the joint. Synovectomy is the excision of the synovial membrane. Tenorrhaphy is the suturing of a tendon. An osteotomy alters the distribution of the weight within the joint.

The nursing diagnosis identified for a patient with OA is acute pain. Which action by the patient warrants intervention by the visiting nurse? A. Acetaminophen (Tylenol) taken PO in doses no more than 3,000 mg/day B. Capsaicin (Capsin) applied topically as needed 3 to 4 times a day C. Cold application to localized area for 30 minutes 4 to 5 times a day D. Paraffin dips providing concentrated heat applied to the wrist before bedtime

C. Cold application to localized area for 30 minutes 4 to 5 times a day RATIONALE Cold application should be limited to no more than 20 minutes. Other actions are appropriate and do not warrant the nurse to intervene. Tylenol maximum dose is usually 1,000 mg every 6 hours with a total of 4 gm. Capsaicin to affected area provides temporary pain relief, application no more than 4 times in 24 hours. Paraffin baths are helpful to patients with wrist and small-joint involvement.

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? A. azathioprine B. diclofenac C. hydroxychloroquine D. cyclophosphamide

C. hydroxychloroquine RATIONALE 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.

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

D. Protect the hands and feet from cold. RATIONALE Raynaud's phenomenon is associated with scleroderma. Client teaching must include strategies for protecting the feet and hands.

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? A. Glucosuria B. Hyperuricemia C. Hyperproteinuria D. Ketonuria

Hyperuricemia RATIONALE Gout is caused by hyperuricemia (increased serum uric acid).