Lewis - Chapter 65: Arthritis and Connective Tissue Diseases

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During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would expect the patient to report (select all that apply)? a. sleep disturbances. b. multiple tender points. c. cardiac palpitations and dizziness. d. multijoint pain with inflammation and swelling. e. widespread bilateral, burning musculoskeletal pain.

ANS: A, B, C, E These symptoms are commonly described by patients with FMS. Cardiac involvement and joint inflammation are not typical of FMS.

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

ANS: A, B, E These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia

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

ANS: B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient

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

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

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

11. b. Rheumatoid nodules develop in 20% to 30% of patients with RA. Felty syndrome is most common in patients with severe, nodule-forming RA. It is characterized by splenomegaly and leukopenia. Sjögren's syndrome occurs as a disease by itself or with other arthritic disorders. Lyme disease is a spirochetal infection transmitted by an infected deer tick bite. Spondyloarthropathies are interrelated multisystem inflammatory disorders that affect the spine, peripheral joints, and periarticular structures but they do not have serum antibodies.

Which drug that prevents binding of the tumor necrosis factor and inhibits the inflammatory response is used in the management of RA? a. Anakinra (Kineret) b. Entanercept (Enbrel) c. Leflunomide (Arava) d. Azathioprine (Imuran)

12. b. Entanercept binds to tumor necrosis factor (TNF) and blocks its interaction with the TNF cell surface receptors, which decreases the inflammatory response. Anakinra is an interleukin-1 receptor antagonist, thus decreasing the inflammatory response. Leflunomide is an antiinflammatory that inhibits proliferation of lymphocytes. Azathioprine is an immunosuppressant that inhibits DNA, RNA, and protein synthesis.

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

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

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

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

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

15. b. Most patients with RA experience morning stiffness and morning activities should be scheduled later in the day after the stiffness subsides. A warm shower in the morning and time to become more mobile before activity are advised. Management of RA includes daily exercises for the affected joints and protection of joints with devices and movements that prevent joint stress. Splinting should be done during an acute flare to rest the joint and prevent further damage.

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

ANS: B Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cell (RBC) count, or lymphocytes.

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

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

After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when what is said by the patient? a. "Heat treatments should not be used if muscle spasms are present." b. "Cold applications can be applied for 15 to 20 minutes to relieve joint stiffness." c. "I should use heat applications for 20 minutes to relieve the symptoms of an acute flare." d. "When my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain."

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

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

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

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

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

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

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

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

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

Which descriptions are related to reactive arthritis (select all that apply)? a. Methotrexate is a treatment of choice b. Symptoms include urethritis and conjunctivitis c. Diagnosed by finding of hypersensitive tender points d. Increased risk in persons with decreased host resistance e. Infection of a joint often caused by hematogenous route f. Self-limiting arthritis following GI (enteral) or sexually transmitted infections

24. b, f. Reactive arthritis is self-limiting and follows GI or sexually transmitted infection, with symptoms including urethritis and conjunctivitis. Methotrexate is the treatment of choice for psoriatic arthritis. Hypersensitive tender points diagnose fibromyalgia. There is increased risk of septic arthritis in persons with decreased host resistance. Joint infection may be caused by the hematogenous route.

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

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

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

ANS: C Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress.

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

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

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

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

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

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

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

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

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

5. a. Some relief for moderate to severe arthritic pain but not for mild arthritic pain has been observed with the use of over-the-counter glucosamine and chondroitin sulfate. These substances should be discontinued if there are no effects after consistent use over 90 to 120 days. They may decrease the effectiveness of antidiabetic drugs and increase the risk of bleeding.

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

6. a. Common side effects of nonsteroidal antiinflammatory drugs (NSAIDs) include gastrointestinal (GI) irritation and bleeding, dizziness, rash, headache, and tinnitus. Misoprostol (Cytotec) is used to prevent NSAID-induced gastric ulcers and gastritis and would increase the patient's tolerance of any of the NSAIDs. The use of naproxen would cause the same gastric effects as ibuprofen. The daily dose of acetaminophen should not exceed 4 g/day to prevent liver damage and antacids interfere with the absorption of NSAIDs.

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

7. a. OA is not systemic or symmetric. Morning joint stiffness resolves in about 30 minutes. Rheumatoid arthritis (RA) is rheumatoid factor (RF) positive and characterized by being systemic and affecting small joints symmetrically. Morning joint stiffness lasts 60 minutes to all day.

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

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

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

9. c. In early disease, the fingers of the patient with moderate RA (1) may become spindle shaped from synovial hypertrophy and thickening of the joint capsule, (2) have no joint deformities but may have limited joint mobility, (3) have adjacent muscle atrophy, and (4) may be inflammed. Splenomegaly may be found with Felty syndrome in patients with severe nodule-forming RA. Heberden's nodes and crepitus on movement are associated with osteoarthritis.

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

A. Some patients find these supplements helpful for relieving arthritis knee pain and improving mobilitiy

A patient taking ibuprofen (Motrin) for treatment of OA has good pain relief but is experiencing increased dyspepsia and nausea with the drug's use. The nurse consults the patient's primary care provider about a. adding misoprostol (Cytotec) to the patient's drug regimen b. substituting naproxen (Naprosyn) for the ibuprofen (Motrin) c. administering the ibuprofen with antacids to decrease the GI irritation d. returning to the use of acetaminophen, but at a dose of 5 g/day instead of 4 g/day

A. adding misoprostol (Cytotec) to the patient's drug regimen

The pathophysiology of systemic lupus erthematosus (SLE) is characterized by a. destruction of nucleic acids and other self-proteins by autoantibodies b. overproduction of collagen that disrupts the functioning of internal organs c. formation of abnormal IgG that attaches to cellular antigens, activating complement d. increased activity of T-suppressor cells with B-cell hypoactivity, resulting in an immunodeficiency

A. destruction of nucleic acids and other self-proteins by autoantibodies

Teaching that the nurse will plan for the patient with SLE includes a. ways to avoid exposure to sunlight b. increasing dietary protein and carbohydrate intake c. the necessity of genetic counseling before planning a family d. the use of no pharmacologic pain interventions instead of analgesics

A. ways to avoid exposure to sunlight

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

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

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

ANS: A Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for a change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve symptoms.

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

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

Which assessment finding about a patient who has been using naproxen (Naprosyn) for 3 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider? a. The patient has dark colored stools. b. The patient's pain has not improved. c. The patient is using capsaicin cream (Zostrix). d. The patient has gained 3 pounds over 3 weeks.

ANS: A Dark colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by the naproxen. The information about the patient's ongoing pain and weight gain also will be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

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

ANS: A Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA). Stiffness in OA is worse right after the patient rests and decreases with joint movement

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

ANS: A Plaquenil can cause retinopathy. The medication should be stopped. The other findings are not related to the medication although they will also be reported.

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

ANS: A Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

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

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

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

ANS: A The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment

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

ANS: A The low blood pressure suggests that the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should also be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

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

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

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

ANS: A Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or NSAIDs, and these should not be discontinued.

After teaching a patient diagnosed with progressive systemic sclerosis about health maintenance activities, the nurse determines that additional instruction is needed when the patient says, a. "I should lie down for an hour after meals." b. "Paraffin baths can be used to help my hands." c. "Lotions will help if I rub them in for a long time." d. "I should perform range-of-motion exercises daily."

ANS: A Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective.

A patient with an acute attack of gout is treated with colchicine. The nurse determines that the drug is effective upon finding a. relief of joint pain. b. increased urine output. c. elevated serum uric acid. d. decreased white blood cells (WBC).

A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing a side effect of the medication? a. The patient's blood glucose is 165 mg/dL. b. The patient has no improvement in symptoms. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.

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

Which statement by a 24-year-old woman with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurse's teaching about management of the condition? a. "I will use a sunscreen whenever I am outside." b. "I will try to keep exercising even if I am tired." c. "I should take birth control pills to keep from getting pregnant." d. "I should not take aspirin or nonsteroidal anti-inflammatory drugs."

ANS: A Severe skin reactions can occur in patients with SLE who are exposed to the sum. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal anti-inflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with a. a warm bath followed by a short rest. b. a short routine of isometric exercises. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

A patient who had arthroscopic surgery of the left knee 5 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? a. The blood pressure is 88/46 mm Hg. b. The white blood cell count is 14,200/µL. c. The patient is taking ibuprofen (Motrin). d. The patient says the knee is very painful.

ANS: A The low blood pressure suggests that the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and also should be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

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

ANS: B Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress. When stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve the flexibility and strength of the affected joints, and the patient's overall endurance.

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

ANS: B Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective

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

ANS: B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

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

ANS: B Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

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

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

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

ANS: B Dark-colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by the naproxen. The information about the patient's ongoing pain and weight gain also will be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate

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

ANS: B Deep-breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

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

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

Which finding will the nurse expect when assessing a 60-year-old patient who has osteoarthritis (OA) of the left knee? a. Heberden's nodules b. Pain upon joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

ANS: B Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA), and stiffness in OA is worse right after the patient rests and decreases with joint movement.

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

ANS: B Keeping the room warm will decrease the incidence of Raynaud's phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose levels or to assist the patient to the bathroom every 2 hours.

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

ANS: B Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

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

ANS: B Monitoring and documenting patients' oral intake is included in UAP education and scope of practice. Assessments for changes in physical status and administration of medications require more education and scope of practice, and should be done by licensed nurses.

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

ANS: B No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management.

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

ANS: B No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management.

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

ANS: B Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

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

ANS: B The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process

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

ANS: B The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself.

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

ANS: B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints as well as improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

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

ANS: B Corticosteroid use is associated with increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne also are adverse effects of corticosteroid use, but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

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

ANS: B Deep breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

A patient has systemic sclerosis manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep patient's room warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

The health care provider has prescribed the following collaborative interventions for a 49-year-old who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Use naproxen (Aleve) 200 mg BID. d. Take famotidine (Pepcid) 20 mg daily.

ANS: B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

A patient with gout tells the nurse that he takes losartan (Cozaar) for control of the condition. The nurse will plan to monitor a. blood glucose. b. blood pressure. c. erythrocyte count. d. lymphocyte count.

ANS: B Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cell count (RBC), or lymphocytes.

After obtaining the health history from a 28-year-old woman who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information about the patient is most important for the nurse to report to the health care provider? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to have a baby before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

ANS: B Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

A 22-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. has a parent who has reactive arthritis. b. is sexually active and has multiple partners. c. recently returned from a trip to South America. d. had several sports-related knee injuries as a teenager.

ANS: B Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.

When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to a. stand rather than sit when performing household chores. b. avoid activities that require continuous use of the same muscles. c. strengthen small hand muscles by wringing sponges or washcloths. d. protect the knee joints by sleeping with a small pillow under the knees.

ANS: B Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion (ROM).

The nurse obtains this information when assessing a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis. Which symptom is most important to report to the health care provider? a. Abdominal cramping b. Complaint of blurry vision c. Phalangeal joint tenderness d. Blood pressure 170/84 mm Hg

ANS: B Plaquenil can cause retinopathy; the medication should be stopped. The other findings are not related to the medication, although they also will be reported.

When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus (SLE), which result is most important to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate? a. "You may need to see a family therapist for some help." b. "Tell me more about the situations that are causing stress." c. "Perhaps it would be helpful for you and your family to get involved in a support group." d. "Your family may need some help to understand the impact of your rheumatoid arthritis."

ANS: B The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

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

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

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

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

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

ANS: C Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued.

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

ANS: C Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

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

ANS: C Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain relief.

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

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

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

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

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

ANS: C Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA.

When caring for a patient who has osteoarthritis, the nurse will anticipate the need to teach the patient about which of these medications? a. Adalimumab (Humira) b. Prednisone (Deltasone) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

ANS: C Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA.

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate (Rheumatrex). The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The most appropriate response by the nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

ANS: C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

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

ANS: C Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis

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

ANS: C OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve nonrepetitive work and thus would not be as risky.

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

ANS: C Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis.

A patient who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that rheumatoid nodules are present on the patient's elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injection of the nodule. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodule.

ANS: C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence

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

ANS: C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

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

ANS: C The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.

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

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

When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information is most important to communicate to the health care provider? a. The blood glucose is 75 mg/dL. b. The rheumatoid factor is positive. c. The white blood cell (WBC) count is 1500/L. d. The erythrocyte sedimentation rate is elevated.

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

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

A patient with rheumatoid arthritis refuses to take the prescribed methotrexate (Rheumatrex), telling the nurse "That drug has too many side effects. My arthritis isn't that bad yet." The most appropriate response by the nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

Which of these patients seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)? a. A 56-year-old man who is a member of a construction crew b. A 24-year-old man who participates in a summer softball team c. A 49-year-old woman who works on an automotive assembly line d. A 36-year-old woman who is newly diagnosed with diabetes mellitus

A 26-year-old patient with urethritis and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with a. anakinra (Kineret). b. etanercept (Enbrel). c. doxycycline (Vibramycin). d. methotrexate (Rheumatrex).

When caring for a patient with gout and a red and painful left great toe, which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the left foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach patient to avoid use of acetaminophen (Tylenol).

ANS: C Since any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by the urate crystals. Acetaminophen can be used for pain relief.

To determine whether a patient with joint swelling and pain has systemic lupus erythematosus, which test will be most useful for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

ANS: C The anti-Sm is antibody found almost exclusively in SLE. The other blood tests also are used in screening but are not as specific to SLE.

While working at a summer camp, the nurse notices a circular lesion with a red border and clear center on the arm of a patient who is in the camp clinic complaining of chills and muscle aches. Which action should the nurse take next? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.

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

ANS: C The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself.

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

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

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

ANS: D Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will also be reported to the health care provider but is consistent with the patient's diagnosis of osteoarthritis and will not require an immediate change in the patient's treatment plan.

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

ANS: D Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion (ROM).

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

ANS: D The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective.

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

ANS: D The patient's statement about not going anywhere because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

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

ANS: D Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

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

A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I hate the way I look! I never go anywhere except here to the health clinic." An appropriate nursing diagnosis for the patient is a. activity intolerance related to fatigue and inactivity. b. impaired social interaction related to lack of social skills. c. impaired skin integrity related to itching and skin sloughing. d. social isolation related to embarrassment about the effects of SLE.

A patient recovering from an acute exacerbation of RA tells the nurse she is too tired to bathe. The nurse should a. give the patient a bed bath to conserve her energy b. allow the patient a rest period before showering with the nurses' help c. tell the patient that she can skip bathing if she will walk in the hall later d. inform the patient that it is important for her to maintain self-care activities

B. allow the patient a rest period before showering with the nurses' help

A patient with gout is treated with drug therapy to prevent future attacks. The nurse teaches the patient that is is the most important to a. avoid all foods high in purine, such as organ meats b. have periodic determination of serum uric acid levels c. perform active ROM of all joints that have been affected by gout d. increase the dosage of medication with the onset of an acute attack

B. have periodic determination of serum uric acid levels

During treatment of the patient with an acute attack of gout, the nurse would expect to administer a. aspirin b. colchicine c. allopurinol (Zyloprim) d. probenecid (Benemid)

B. Colchicine

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

B. I should perform most of my daily chores in the morning when my energy level is highest

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

B. it is difficult to tell because the disease is so variable in its severity and progression

To preserve function and the ability to perform activities of daily living, the nurse teaches the patient with OA to a. avoid exercise that involves the affected joints b. plan and organize less stressful ways to perform tasks c. maintain normal activities during an acute episode to prevent loss of function d. use mild analgesics to control symptoms when performing tasks that cause pain

B. plan and organize less stressful ways to perform tasks

The nurse teaches the patient with RA that one of the most effective methods of aerobic exercise is a. ballet dancing b. casual walking c. aquatic exercises d. low-impact aerobic exercises

C. aquatic exercises

During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the steroids to begin to be tapered when serum laboratory results indicate a. increased RBCs b. decreased ESR c. decreased anti-DNA d. increased complement

C. decreased anti-DNA

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

C. drug interactions and toxicity are more likely to occur with multidrug therapy

A patient with OA uses NSAIDs to decrease pain and inflammation. The nurse teaches the patient that common side effects of these drugs include a. allergic reactions, fever, and oral lesions b. fluid retention, hypertension, and bruising c. skin rashes, gastric irritation, and headache d. prolonged bleeding time, blood dyscrasias, and hepatic damage

C. skin rashes, gastric irritation, and headacche

During the physical assessment of the patient with moderate RA, the nurse would expect to find a. hepatomegaly b. Heberden's nodes c. spindle-shaped fingers d. crepitus on joint movement

C. spindle-shaped fingers

When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which of the following statements? A. "I should take the Celebrex 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."

Correct answer: B. "I should try to stay standing all day to keep my joints from becoming stiff." Rationale: It is important to maintain a balance between rest and activity to prevent overstressing the joints with OA.

The 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 describes the condition as which of the following? 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

Correct answer: B. Degeneration of articular cartilage in synovial joints Rationale: OA is a degeneration or breakdown of the articular cartilage in synovial joints. The condition has also been referred to as degenerative joint disease.

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 which of the following? A. Use a wheelchair to avoid walking as much as possible. B. Eat a well-balanced diet to maintain a healthy body weight. C. Incorrect Use a walker for ambulation to relieve the pressure on her hips. D. Sit in chairs that do not cause her hips to be lower than her knees.

Correct answer: B. Eat a well-balanced diet to maintain a healthy body weight. Rationale: 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.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Which of the following findings would 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

Correct answer: B. Pain with joint movement Rationale: OA is characterized predominantly by joint pain upon movement and is a classic feature of the disease.

A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the 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."

Correct answer: C. "I'm hoping that surgery will be an option for me in the future." Rationale: SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.

The 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 of the following activity patterns? A. Bed rest with bathroom privileges B. Daily high-impact aerobic exercise C.A regular exercise program of walking D. Frequent rest periods with minimal exercise

Correct answer: C. A regular exercise program of walking Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in the patient with osteoarthritis.

Which of the following patient statements 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."

Correct answer: D. "My lower back pain seems to be getting worse all the time and nothing seems to help." Rationale: 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.

The nurse is reinforcing general health teaching with a 64-year-old patient with osteoarthritis (OA) of the hip. Which of the following points would the nurse include in this review of the disorder (select all that apply)? A. OA cannot be successfully treated with any current therapy options. B. OA is an inflammatory disease of the joints that may present symptoms at any age. C.Joint degeneration with pain and disability occurs in the majority of people by the age of 60. D. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling. E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication.

Correct answer: D. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling. E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication. Rationale: OA occurs with greater frequency with increasing age, but it usually remains confined to a few joints and can be managed with a combination of exercise, diet, and medication. OA can lead to significant disability.

Teach the patient with ankylosing spondylitis the importance of a. regular exercise and maintaining proper posture b. continuing with physical activity during flare-ups c. avoiding extremes in environmental temperatures d. applying 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 to minimize 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 the 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.

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

Correct answer: b Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for long-term management of hyperuricemia in persons with chronic gout. Acute gouty arthritis is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs).

In teaching a patient with chronic fatigue syndrome (CFS) about this disorder, the nurse understands that a. palpating tender points is an indicator of CFS severity b. many symptoms are similar to fibromyalgia syndrome c. definitive treatment includes low-dose hydrocortisone d. CFS is characterized by progressive memory impairment

Correct answer: b Rationale: Fibromyalgia syndrome (FS) and chronic fatigue syndrome (CFS) have several commonalities. Both occur in previously healthy, young, and middle-aged women; the cause of both includes an infectious trigger, dysfunction of the hypothalamic-pituitary-adrenal axis or an alteration in central nervous system; and common clinical manifestations are malaise and fatigue, cognitive dysfunction, headaches, sleep disturbances, depression, anxiety, fever, and generalized musculoskeletal pain. Both diseases have symptoms that fluctuate over time, and both disorders have no definitive laboratory tests or joint and muscle examinations. They remain diagnoses of exclusion. Treatment for both disorders is symptomatic and may include antidepressant drugs. Other measures are heat, massage, regular stretching, biofeedback, stress management, and relaxation training.

Assessment data in the patient with osteoarthritis commonly include a. gradual weight loss b. elevated WBC count c. joint pain that worsens with use d. straw-colored synovial fluid

Correct answer: c Rationale: Osteoarthritis pain ranges from mild discomfort to significant disability. Joint pain is the predominant symptom, and the pain generally worsens with joint use.

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.

In assessing the joints of a patient with rheumatoid arthritis, the nurse understands that the joints are damaged by (select all that apply) a. bony ankylosis following inflammation of the joints b. the deterioration of cartilage by proteolytic enzymes c. the development of Heberden's nodes in the joint capsule d.. increased cartilage and bony growth at the joint margins e. invasion of pannus into the joint causing a loss of cartilage

Correct answers: a, e Rationale: Bony ankylosis is the union of the bones of a joint by proliferation of bone cells, resulting in complete immobility. Bony ankylosis occurs with advanced rheumatoid arthritis. Joint changes from chronic inflammation begin when the hypertrophied synovial membrane invades the surrounding cartilage, ligaments, tendons, and joint capsule. Pannus (i.e., highly vascular granulation tissue) forms within the joint. It eventually covers and erodes the entire surface of the articular cartilage. The production of inflammatory cytokines at the pannus-cartilage junction further contributes to cartilage destruction. The pannus scars and shortens supporting structures such as tendons and ligaments, ultimately causing joint laxity, subluxation, and contracture.

When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to (select all that apply) a. avoiding the consumption of high-purine foods b. strategies for good dental hygiene and mouth care c. protecting the extremities from hot and cold temperatures d. maintaining joint function and preserving muscle strength e. performing mouth excursion (yawning) exercises on a daily basis

Correct answers: b, c, d, e Rationale: Systemic sclerosis (SS), or scleroderma, is a disorder of connective tissue characterized by fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs. The nurse should include the following in the teaching plan for a patient with SS: daily oral hygiene (neglect may increase tooth and gingival problems); protection of hands and feet from cold exposure and possible burns or cuts (wounds heal slowly); avoidance of emotional stress and cold ambient temperatures (they aggravate Raynaud's phenomenon); isometric exercises for arthropathy (no joint movement occurs); use of assistive devices as appropriate and organization of activities to preserve strength and reduce disability; and mouth excursion (i.e., yawning with an open mouth) (helps maintain temporomandibular joint function).

The basic pathophysiologic process of rheumatoid arthritis (RA) is a. destruction of joint cartilage and bones by an autoimmune process b. initiated by a viral infection that destroys the synovial membranes of joints c. the presence of HLA-DR4 antigen that causes inflammatory responses throughout the body d. an immune response that activates complement and produces inflammation of joints and other organ systems

D. an immune response that activates complement and produces inflammation of joints and other organ systems

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

D. changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age.

Characteristics of spondyloarthritides associated with HLA-B27 antigen include a. symmetric polyarticular arthritis b. an absence of extraarticular disease c. presence of rheumatoid factor and autoantibodies d. high level of involvement of sacroiliac joints and the spine

D. high level of involvement is sacroiliac joints and the spine

Laboratory findings that the nurse would expect to be present in the patient with RA include a. polycythemia b. increased IgG c. decreased WBC d. increased C-reactive protein (CRP)

D. increased C-reactive protein (CRP)

An important nursing intervention for the patient with ankylosing spondylitis is to teach the patient to a. wear roomy shoes with good orthotic support b. sleep on the side with the knees and hips flexed c. keep the spine slightly flexed while sitting, standing, or walking d. perform back, neck, and chest stretches and deep breathing exercises

D. perform back, neck and chest stretches and deep breathing exercises

A patient is seen at the outpatient clinic for a sudden onset of inflammation and severe pain in the great toe. A diagnosis of gout is made on the basis of a. a family history of gout b. elevated urine uric acid levels c. elevated serum uric acid levels d. the presence of sodium urate crystals in synovial fluid

D. the presence of sodium urate cystals in synovial fluid

After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when the patient says, a. heat treatments should not be used if muscle spasms are present b. cold applications can be applied for 15-20 minutes to relieve joint stiffness c. I should use heat applications for 20 minutes to relieve the symptoms of an acute flare d. when my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain

D. when my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relive the pain

Number in sequence from 1 to 6 the pathophysiologic processes that occur in osteoarthritis (OA). ________ a. Erosion of articular surfaces ________ b. Incongruity in joint surfaces ________ c. Reduction in motion ________ d. Joint cartilage becomes yellow and granular ________ e. Osteophytes form at joint margins ________ f. Cartilage becomes softer and less elastic

a. 3; b. 5; c. 6; d. 1; e. 4; f. 2

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

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

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

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

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

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

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