Patho PrepU ch 44
When teaching a community education class on osteoarthritis (OA), the nurse should include which of the following in discussing which individuals are at risk for this problem? Select all that apply.
-Elderly individuals -Older women -Obese people Explanation: Eighty-five percent of people with OA are in their seventies. Men are affected more commonly at a younger age, however, by 55 years of age; women are the more frequent gender affected. Obesity is a risk; Chinese individuals have a lower incidence of OA than Europeans. Page 1128
A 7-year-old child has been diagnosed with renal failure due to autoimmune glomerulonephritis. Knowing the potential complications of this disease, the nurse should closely monitor the client for signs and symptoms of:
rickets. Explanation: Rickets is a metabolic bone disorder characterized by a failure or delay in calcification of the cartilaginous growth plate in children whose epiphyses have not yet fused, which may arise from renal failure. Osteomyelitis is a bone infection, osteoporosis is marked by bone loss, unrelated to kidney disease. Similarly, Paget disease is not a potential result of renal failure. Page 1115
The nurse determines further teaching is necessary when a client diagnosed with osteoarthritis states:
"Men are more likely to have osteoarthritis than women." Explanation: Women are more likely to have osteoarthritis than men, and they tend to have more severe osteoarthritis as well. The other options are correct. Page 1128
When a nurse is caring for a patient who has systemic lupus erythematosis (SLE), which of the following causes the disease?
Autoimmune process Explanation: The cause of SLE is unknown. It is characterized by the formation of autoantibodies and immune complexes. Page 1123
Juvenile dermatomyositis is a chronic inflammatory myopathy that commonly manifests systemically. What is the treatment of choice for this myopathy?
Corticosteroids Explanation: Corticosteroids are the mainstay of treatment for these conditions. The other drug types are not the treatment of choice for polymyositis and dermatomyositis. Page 1135
The nurse assessing a patient with scleroderma with CREST variant would include an assessment for which of the following?
Raynaud's phenomenon Explanation: Raynaud's phenomenon is the characteristic symptom of CREST variant of scleroderma that is identified by the R in the CREST acronym. The other options are associated with systemic lupus erythematosus. Page 1125
A nurse is caring for a patient admitted with a malar rash on the nose and cheeks. The nurse recognizes that this rash is characteristic of which of the following disease processes?
Systemic lupus erythematosus Explanation: The acute skin lesions include the classic malar or "butterfly" rash on the nose and cheeks. Page 1124
A patient has been diagnosed with rheumatoid arthritis (RA). Which of the following will the nurse tell the patient about this disorder's etiology?
"Genetic predisposition is very likely." Explanation: The cause of RA is uncertain but evidence points to genetic predisposition. The disease usually occurs later in life. Page 1119
The parents of a child diagnosed with rheumatic disease are shocked by the diagnosis and tell the nurse that they did not think children could acquire the disease. The best response would be:
"Children can be affected with almost all of the rheumatic diseases that occur in adults." Explanation: Children can be affected by many of the same types of rheumatic diseases that occur in adults. The disease may affect both child and family and can seriously impact a child's growth and development, limit the child's participation in childhood activities, and require an extensive plan of drug treatment and rehabilitation. Page 1133
A 64 year-old man was diagnosed 19 months ago with bilateral osteoarthritis (OA) in his knees, and has come to his family physician for a checkup. The client and his physician are discussing the affects of his health problem and the measures that the man has taken to accommodate and treat his OA in his daily routines. Which of the following statements by the client would necessitate further teaching?
"I've been avoiding painkillers because I know they can mask damage that I might be inflicting on my knees." Explanation: Analgesics are a common and appropriate treatment for OA, and it would be unnecessary and inappropriate to forego pain control in order to maximize pain signals from affected joints. Weight loss, the use of assistive devices and muscle-strengthening exercises are appropriate treatments for OA. Page 1130
A client diagnosed with Paget disease asks the health care provider how the disease developed. The best response would be:
"It is thought to have a probable association with a viral infection: paramyxovirus." Explanation: Paget disease may be linked to both genetic and environmental influences: a positive family history, mutations in genes encoding proteins in the RANK signaling pathway, and/or a probable association with a virus, possibly a paramyxovirus, suggesting that a viral infection may serve as a trigger for development of Paget disease in genetically predisposed individuals. A more sedentary lifestyle will reduce the mechanical loading of the skeleton and may decrease the incidence and severity of Paget disease. Page 1117
A client sought care because of increasing pain and inflammation in the toe and ankle of one foot. Diagnostic testing has resulted in a diagnosis of gouty arthritis. When educating the client about the treatment and management of the disease, what should the nurse teach the client?
"Losing some weight and reducing your alcohol intake will likely be beneficial." Explanation: For many clients with gout, changes in lifestyle may be needed, such as maintenance of ideal weight, moderation in alcohol consumption, and avoidance of purine-rich foods. Weekly blood work is not necessary and NSAIDs are preferred to opioids for pain management. Physiotherapy is not a major treatment modality for gout. Page 1131
A nurse is teaching a group of nursing students about the presentation of systemic lupus erythematosus (SLE). Which of the following statements does the nurse is likely to make?
"More women than men are affected by lupus." Explanation: There is a female predominance of 10:1 in those with SLE. This ratio is closer to 30:1 during childbearing years. SLE is more common in African Americans, Hispanics, and Asians than in whites, and the incidence in some families is higher than in others. Page 1123
The nurse is caring for a patient diagnosed with osteoarthritis (OA). Which of the following does the nurse teach the patient about the disease?
"OA is a disease of the weight-bearing joints." Explanation: OA is a slowly progressive destruction of articular cartilage of weight-bearing joints and fingers of older adults and the joints of younger people who have experienced trauma. Page 1130
Following a progressive onset of fatigue, aching and joint stiffness over the last two years, a 69 year-old male has recently been diagnosed with rheumatoid arthritis (RA). Which of the following teaching points should his primary care physician include during the office visit in which this diagnosis is communicated to the client?
"Steroids and anti-inflammatory drugs that I'll prescribe will likely bring some relief to your symptoms." Explanation: Current treatment guidelines for RA involve early and aggressive pharmacological treatment, including NSAIDs and corticosteroids. Damage cannot be reversed, and while therapeutic exercise plays a role in treatment, rest is also important. Page 1123
A 36 year-old female who has experienced diverse symptoms for several years has finally had her health problems attributed to scleroderma (systemic sclerosis), and has committed herself to learning as much about the disease as she can. Which of her following statements would her nurse want to correct or clarify?
"The worst part of this so far has been learning that there aren't any treatments for scleroderma." Explanation: While the cause of scleroderman remains unknown, supportive treatments that address symptoms do exist. Reynaud phenomenon is a very common accompaniment to the disease and cardiac and pulmonary involvement is common. Page 1125
The nurse determines that additional patient education is needed when a patient with gout makes which one of the following statements?
"When I have an exacerbation of my symptoms, a glass of red wine will be helpful." Explanation: The statement about drinking alcohol to decrease the symptoms would need more follow-up, since it is a strong contributor to an exacerbation of gout. The other statements are valid. Page 1132
Osteoarthritis is the most common cause of arthritis and a significant cause of disability in the elderly. What joint changes occur in osteoarthritis? (Select all that apply.)
-Creation of spurs -Loss of articular cartilage -Synovitis Explanation: The joint changes associated with osteoarthritis, which include a progressive loss of articular cartilage and synovitis, result from the inflammation caused when cartilage attempts to repair itself, creating osteophytes or spurs. These changes are accompanied by joint pain, stiffness, limitation of motion, and, in some cases, joint instability and deformity. The other answers are incorrect Page 1129
A 68 year-old woman has had her mobility and quality of life severely affected by rheumatoid arthritis (RA). Place the following pathophysiological events involved in her health problem in the correct order that they most likely occurred. Use all the options.
-Inflammatory response -Interaction between rheumatoid factor (RF) and IgG -T-cell mediated immune response -Pannus invasion -Destruction of articular cartilage Explanation: RA is thought to begin with a T-cell mediated immune response which precipitates interaction between IgG and RF that constitutes an immune response. Pannus invasion is one consequence of this interaction, the ultimate result of which is destruction of cartilage. Page 1119
A nurse is assessing a patient with rheumatoid arthritis (RA). What does the nurse expect to find when evaluating the patient's joints? (Select all that apply.)
-Joint pain lasting for 30 minutes to several hours -Decreased joint motion -Nodules on joints Explanation: Patients with RA generally have joint pain lasting for 30 minutes to several hours, decreased joint motion, and nodules on joints. The involvement is symmetrical, occurring on both sides at once. Page 1120
Scleroderma is an autoimmune disease of connective tissue that is characterized by hardening of the skin. What diseases do almost all people with scleroderma develop? (Select all that apply.)
-Polyarthritis -Raynaud phenomenon Explanation: Almost all persons with scleroderma develop polyarthritis and Raynaud phenomenon, a vascular disorder characterized by reversible vasospasm of the arteries supplying the fingers. Dumping syndrome, chronic diarrhea, and chronic vasoconstriction are not diseases developed by people with scleroderma. Page 1125
An older adult's primary care provider has deemed the client to be at a high risk for developing osteomalacia. What current laboratory findings would support this conclusion? Select all that apply.
-Serum phosphorus level of 0.55 mmol/l (normal 1.0 to 1.5 mmol/l) -Serum calcium level of 1.4 mmol/l (normal 2.1 to 2.6 mmol/l) -25-hydroxy vitamin D level of 10.1 nmol/l (normal 19.4 to 137 nmol/l) Explanation: Osteomalacia is a generalized bone condition in which there is inadequate mineralization of bone. There are two main causes of osteomalacia: (1) insufficient calcium absorption from the intestine because of a lack of dietary calcium or a deficiency of or resistance to the action of vitamin D; and (2) phosphate deficiency caused by increased renal losses or decreased intestinal absorption. The client's low levels of phosphorus, vitamin D derivative, and calcium constitute a high risk for osteomalacia. Low hemoglobin and high potassium levels do not directly relate to this diagnosis. Page 1115
The nurse is caring for a patient with rheumatoid arthritis (RA). Which of the following assessment findings does the nurse expect? (Select all that apply.)
-Weight loss -Fatigue -Anorexia Explanation: RA is characterized by weight loss, generalized aching, anorexia, fatigue, as well as joint changes such as pain and stiffness. Increased appetite and flushed skin are not symptoms of RA. Page 1120
When teaching a patient with rheumatoid arthritis (RA), which of the following factors does the nurse explain is an underlying cause of this disease?
Autologous antibodies Explanation: The pathogenesis of RA can be viewed as an aberrant immune response that leads to synovial inflammation and destruction of the joint architecture. Approximately 70-80% of people with the disease have a substance called rheumatoid factor, which is an autologous (self-produced) antibody that causes joint destruction. Page 1119
A client with confirmed low bone density asks the nurse if there is anything she can to decrease the risk of trauma. The best response would be:
Brisk walking three times per week on a flat surface Explanation: Weight-bearing exercises such as walking, jogging, rowing, and weight lifting are important in the maintenance of bone mass. The other options place the person at risk for injury if the bones are weakened. Page 1114
Which diagnostic finding has been strongly linked to systematic lupus erythematosus (SLE)?
Elevated anti-nuclear antibodies (ANA) Explanation: While there is no laboratory finding that will provide a definite diagnosis of SLE, the ANA is elevated in 95% of untreated SLE. Page 1123
A seronegative inflammatory arthropathy is psoriatic arthritis. What drug has been found to be beneficial in controlling both the psoriasis and the arthritis in these clients?
Etanercept Explanation: The biologic response modifiers, specifically the tumor necrosis factor inhibitors (e.g., etanercept, infliximab, and adalimumab), have been found to be beneficial in controlling the arthritis as well as the psoriasis in clients with psoriatic arthritis. The other drugs have not been found to be beneficial in psoriatic arthritis. Page 1127
Rheumatoid arthritis is a chronic autoimmune system disease that affects a single joint.
False Explanation: Rheumatoid arthritis includes joint involvement that is usually symmetric and polyarticular. Any diarthrodial joint can be involved. Page 1119
When caring for a patient with ankylosing spondylitis, in which position does the nurse place the patient for sleep?
Flat with one pillow Explanation: Proper posture and positioning are important. This includes sleeping in a supine position on a firm mattress and using one small pillow or no pillow. Page 1127
Which statement is true regarding the development of juvenile idiopathic arthritis?
Generalized stunted growth can occur. Explanation: Generalized stunted growth can occur as well as unilateral increased growth related to the influence on epiphyseal growth. It will not resolve in adulthood, and surgical intervention is not an option to eliminate the disease. Page 1134
When caring for a patient with ankylosing spondylitis, the nurse tells the patient that stiffness may be relieved by which of the following interventions?
Gentle exercise Explanation: The pain of ankylosing spondylitis becomes worse when resting, particularly when lying in bed, and may be relieved with physical activity. Lumbosacral pain may also be present, with discomfort in the buttocks and hip areas. Prolonged stiffness is present in the morning and after periods of rest. Mild physical activity or a hot shower helps reduce pain and stiffness. Page 1127
The client with a suspected diagnosis of osteoarthritis asks the health care provider how the diagnosis will be confirmed. The best response would be:
History and physical examination, x-ray studies, and laboratory findings that exclude other diseases Explanation: The diagnosis of OA usually is determined by history and physical examination, x-ray studies, and laboratory findings that exclude other diseases. The other options would not identify the disease. Page 1130
Which of the following pathophysiological phenomena would be most indicative of ankylosing spondylitis?
Loss of motion in the spinal column and eventual kyphosis. Explanation: The characteristic trait of ankylosing spondylitis is progressive loss of spinal ROM and eventual kyphosis. Synovial joint involvement is not associated with the disease and a butterfly rash and multisystem involvement are associated with SLE. Decreased bone density does not normally accompany ankylosing spondylitis. Page 1126
The nurse is assessing a patient with ankylosing spondylitis (AS). Which of the following does the nurse expect to find?
Lower back pain Explanation: The patient with AS has an inflammatory erosion of the sites where tendons and ligaments attach to bone. The disease progresses with bilateral involvement of the sacroiliac joints and produces lower back pain. Joint contractures, butterfly rash, and bruises are not characteristic of this disease. Page 1126
When a nurse is assessing a patient with osteoarthritis, which of the following factors poses a risk factor for the disease?
Obesity Explanation: Obesity is a particular risk factor for OA of the knee in women and a contributory biomechanical factor in the pathogenesis of the disease; OA is a problem occurring in weight-bearing joints. Page 1128
The nurse is conducting a health promotion class on osteoarthitis (OA). Which of the following statements should the nurse include?
Obesity is a strong risk factor for developing OA. Explanation: Obesity is a strong risk factor for OA of the knee in women, and a contributory biomechanical factor in the pathogenesis of the disease. Young men have a higher risk, but after middle age women are more at risk for developing OA. The statements regarding heredity and diet are not true. Page 1128
A 75-year-old Caucasian female has been admitted to the hospital with a hip fracture. She states, "All I did was fall into my chair, not even very hard." Upon diagnostic testing, the client's bones shows loss of trabeculae from cancellous bone and thinning of the cortex. Which diagnosis is most likely?
Osteoporosis Explanation: Osteoporotic changes occur in the diaphysis and metaphysis where a loss of trabeculae from cancellous bone and thinning of the cortex is to such an extent that minimal stress causes fractures. Osteonecrosis is due to ischemia, osteomyelitis is an infection, and osteomalacia is a metabolic disorder caused by phosphate deficiency. Page 1112
Giant cell arthritis is a comorbid condition of which of the following?
Polymalgia rheumatica Explanation: A certain percentage of people with polymyalgia rheumatica also develop giant cell arteritis (i.e., temporal arteritis) with involvement of the ophthalmic arteries. This is not an associated outcome of any of the other options. Page 1136
A patient has been diagnosed with scleroderma. Which of the following assessment findings does the nurse expect?
Raynaud's phenomenon Explanation: Scleroderma presents with multiple clinical symptoms. Raynaud's phenomenon is generally associated with the disorder. Facial rash, increased blood pressure, and cardiac dysrhythmias are not classic symptoms. The acronym CREST is typically used to remember symptoms: calcinosis, Raynaud's, esophageal dysmobility, sclerodactyly, and telangiectasis. In addition, autoantibodies, pulmonary fibrosis, and contraction of digital joints can be found. Page 1125
The health care provider is assessing a client with a history of ankylosing spondylitis, to note progression of the disease. The most important area for the provider to assess would be:
Spine Explanation: Ankylosing spondylitis affects the axial skeleton and manifests by pain and progressive stiffening of the spine. Occasionally, large synovial joints (i.e., hips, knees, and shoulders) may be involved. The other areas would not be affected. Page 1126
While reviewing the following diagnostic findings on a group of patients with joint complaints, which finding would be a priority for further investigation and possible medical intervention?
Synovial fluid aspiration indicates the presence of monosodium urate crystals. Explanation: The presence of crystalline deposits in synovial fluid confirms a diagnosis of gout and would necessitate further investigation and/or treatment. Hyperuricemia is not necessarily indicative of gout, and while diet can contribute to gout, this would not necessarily require modification in the absence of gout. Oral colchicine often takes 48 hours to take effect during an acute attack of gout. Page 1135
The nurse is providing patient education related to intra-articular corticosteroid injections. Which of the following should the nurse include?
The injections will be given only 3-4 times per year because they can increase joint destruction. Explanation: The patient needs to be educated regarding the limited use of the injections and the risk of their causing additional joint destruction. The patient should not be encouraged to run, but can participate in muscle-strengthening exercises. The statements regarding discomfort and daily administration are not correct. Page 1131
Though the client's primary care provider has downplayed the symptoms, a geriatrician suspects that an 82 year-old female has polymyalgia rheumatica. Which characteristic symptomatology would most likely have led the specialist to suspect this health problem?
The woman complains of aching and morning stiffness in her neck, shoulder and pelvis. Explanation: Polymyalgia rheumatica is an inflammatory condition of unknown origin characterized by aching and morning stiffness in the cervical regions and shoulder and pelvic girdle areas. Lower limb pain, wrist and ankle stiffness and pain in the joints of the foot would not be as clearly suggestive of polymyalgia rheumatica. Page 1136
The nurse is teaching a patient with rheumatoid arthritis about pannus, which develops in the affected joint area. Which of the following does the nurse include to describe pannus?
Vascular granulation tissue that destroys cartilage and bone Explanation: A network of new blood vessels in the synovial membrane that contributes to the advancement of the rheumatoid synovitis, called pannus, develops. This destructive vascular granulation tissue extends from the synovium to involve a region of unprotected bone at the junction between cartilage and the subchondral bone. Inflammatory cells found in the pannus have a destructive effect on adjacent cartilage and bone leading to reduced joint motion and the possibility of eventual ankylosis. Page 1120
The nurse is providing care for an adult client whose current medication regimen includes calcitonin and a bisphosphonate. The nurse should recognize the likely need for:
bone density testing on a scheduled basis. Explanation: Calcitonin and bisphosphonates are commonly used in the treatment of osteoporosis, in order to slow bone resorption; individuals with osteoporosis are encouraged to undergo regular bone density testing. Weight-bearing exercise is beneficial, provided it is performed within safe limits. Surgery is not normally indicated. Genu varum and genu valgum are congenital misalignments of the knee joint that do not affect bone resorption. Page 1112
The nurse has just finished teaching a client newly diagnosed with rheumatoid arthritis about the disease. The nurse determines that teaching is effective when the client states:
"Rheumatoid arthritis includes joint involvement that is usually symmetric and polyarticular." Explanation: Joint involvement with rheumatoid arthritis usually is symmetric and polyarticular. Any diarthrodial joint can be involved. The disease is characterized by exacerbations and remissions, may involve only a few joints for brief durations, or may become relentlessly progressive and debilitating. Page 1120
A nurse is caring for a patient with a fractured elbow. Which of the following instructions is important to give the patient to prevent cartilage degeneration while the elbow is immobilized?
"To prevent cartilage atrophy, slowly and gradually resume exercising." Explanation: Cartilage atrophy is rapidly reversible with activity after a period of immobilization; impact exercise during the period of remobilization can prevent reversal of the atrophy. Slow and gradual remobilization may be important in preventing cartilage injury. Page 1130
When working with a patient with diffuse scleroderma who is exhibiting a 'stone face' expression, the nurse should consider which of the following to be a priority nursing diagnosis for this patient?
Aspiration, risk for related to swallowing impairments. Explanation: Diffuse scleroderma is characterized by severe and progressive disease of the skin and the early onset of organ involvement. The typical person has a "stone facies" due to tightening of the facial skin with restricted motion of the mouth. Involvement of the esophagus leads to hypomotility and difficulty swallowing. The other NANDAs would be of lower priority if at all given the assessment data presented. Page 1125
A 16 year-old boy has been diagnosed with ankylosing spondylitis. Which of the following etiologies is responsible for his health problem?
Immune response Explanation: Ankylosing spondylitis is thought to have an etiology that suggests an immune response. Physical wear and tear, infection and inappropriate remodeling are not considered primarily responsible for the disease. Page 1126
In a patient diagnosed with osteomalacia, which of the following would be recommended to aid with improvement of the condition?
Increasing dietary consumption of vitamin D Explanation: Patients with osteomalacia need to have increased vitamin D, and exposure to natural sunlight will help increase the absorption. Losing weight and a bone marrow transplant will not be helpful. Page 1116
A daughter is concerned because her elderly parent has been diagnosed with osteomalacia. The daughter asks the nurse why this happened. The best response would be that:
Intestinal absorption slows as a natural aging process Explanation: The incidence of osteomalacia is high among the elderly because of diets deficient in calcium and vitamin D, a problem often compounded by the intestinal malabsorption that accompanies with aging. Melanin is extremely efficient in absorbing UVB radiation; thus, decreased skin pigmentation markedly reduces vitamin D synthesis, as does the use of sunscreens. Osteomalacia also may occur in persons on long-term treatment with medications such as anticonvulsants (e.g., phenytoin, carbamazepine, valproate) that decrease the activation of vitamin D in the liver. Page 1115
A nurse is caring for a patient with ankylosing spondylitis. For which of these associated symptoms does the nurse assess?
Kyphosis Explanation: Loss of motion in the spinal column is characteristic of the disease. Loss of lumbar lordosis occurs as the disease progresses, followed by kyphosis of the thoracic spine and extension of the neck. Page 1126
Due to her progressing osteoarthritis (OA), an 80 year-old woman is no longer able to perform her activities of daily living without assistance. Which of the following phenomena most likely underlies the woman's situation?
Loss of articular cartilage and synovitis has resulted from inflammation caused when joint cartilage attempted to repair itself. Explanation: The joint changes associated with osteoarthritis, which include a progressive loss of articular cartilage and synovitis, results from the inflammation caused when cartilage attempts to repair itself, creating osteophytes or spurs. These changes are accompanied by joint pain, stiffness, limitation of motion, and in some cases by joint instability and deformity. Immune etiology is more associated with rheumatoid arthritis and collagen deposits are characteristic of scleroderma. Bones do not tend to fuse in the pathogenesis of OA. Page 1128
The nurse is caring for a patient with newly diagnosed systemic lupus erythematosus (SLE). Which of the following over-the-counter medications does the nurse recognize is useful in treating inflammation, arthritis, and pleuritis?
Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: Treatment with medications may be as simple as a drug to reduce inflammation, such as an NSAID. NSAIDs can control fever, arthritis, and mild pleuritis. Page 1125
A 42-year-old client is admitted to the hospital with severe back pain, intermittent tinnitus, constant headache, and vertigo. He states that the back pain has been a problem for a number of years, but the other symptoms are quite new. Upon further examination, it is noted that he has unexplained hearing loss, and his femur and tibia have begun to bow. What condition does this client most likely have?
Paget Disease Explanation: The clinical manifestations of Paget disease that involve the skull results in headaches, intermittent tinnitus, vertigo, and eventual hearing loss. In the spine, collapse of the anterior vertebrae causes kyphosis of the thoracic spine. The femur and tibia also become bowed. Page 1117
The nurse caring for a child with a deficiency of vitamin D knows that the deficiency places the child at risk for which of the following?
Rickets Explanation: Rickets is associated with a Vitamin D deficiency while scurvy is associated with a Vitamin C deficiency. Hip dysplasia is not associated with a Vitamin D deficiency. Paget disease is not associated with children. Page 1115
Which of the following substances helps maintain a smooth surface in joint cartilage?
Synovial fluid Explanation: In combination with synovial fluid, the articular cartilage provides extremely low friction during joint movement. Page 1128
The physician is considering prescribing an anti-tumor necrosis factor (TNF) like infliximab for a rheumatoid arthritis patient. Which of the following statements is accurate about the advantages of using a TNF inhibitor?
TNF inhibitors help slow the disease progression and improve your ability to perform routine ADL functions. Explanation: Second-line anti-rheumatic drugs include anti TNF drugs such as etanercept, infliximab, and adalimumab. These drugs are biologic response-modifying agents or TNF inhibitors that block TNF-α, one of the key proinflammatory cytokines in RA. Anti-TNF-α agents have significant efficacy although they do have some potential adverse side effects. Evidence indicates that CV side effects are not different for TNF inhibitors than for DMARDs. The TNK inhibitor agents also have been show to inhibit radiologic disease progression and improve functional outcomes. Page 1123
Select the statement that best describes systemic lupus erythematosus (SLE). SLE is characterized by which of the following?
The formation of autoantibodies and immune complexes (type III hypersensitivity) Explanation: SLE is characterized by the formation of autoantibodies and immune complexes (type III hypersensitivity; T-cell-mediated response to an immunologic trigger occurs in RA). SLE may be acute or insidious, and the course of the disease is characterized by exacerbations and remissions. Exposure to UV light, specifically UVB associated with exposure to the sun or unshielded fluorescent bulbs, may trigger exacerbations. Page 1123
In general, children are not affected by rheumatic diseases, such as arthritis, that occur in adults.
False Children can be affected by almost all of the rheumatic diseases that occur in adults. Page 1133
A patient recently diagnosed with rheumatoid arthritis (RA) tells the nurse she is glad there is nothing "really wrong with her" but some joint swelling. Which of the following information should the nurse tell the patient about RA?
"Extra-articular manifestations may include anemia and deformities of the affected joints." Explanation: Although characteristically a joint disease, RA can affect a number of other tissues including red blood cells, blood vessels, lungs, and heart. Treatment goals for a person with RA are to prevent and/or reduce the pain, decrease stiffness and swelling, maximize mobility, and possibly halt the progression, but not cure the disease. Page 1120
The nurse is reviewing the health histories of four clients. Select the client most at risk for developing secondary osteoporosis.
A 60-year-old female taking prednisone for asthma Explanation: Corticosteroid (e.g., prednisone) use is the most common cause of drug-related osteoporosis, and long-term corticosteroid use in the treatment of disorders such as rheumatoid arthritis and chronic obstructive lung disease is associated with a high rate of fractures. The prolonged use of aluminum-containing antacids, which increase calcium excretion, and anticonvulsants, which impair vitamin D production, may also contribute to bone loss. Persons with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) who are being treated with antiretroviral therapy are also at risk. The other options would not cause osteoporosis. Page 1112
The health care provider has determined that a client has developed rheumatoid arthritis. The provider is aware that the client may experience joint inflammation that involves of immunologic mediation triggered by:
A T-cell mediated response to an immunologic trigger, such as a microbial agent Explanation: Rheumatoid arthritis is initiated in a genetically predisposed individual by the activation of a T-cell-mediated response to an immunologic trigger, such as a microbial agent. Activation of CD4+ helper T cells occurs with the local release of inflammatory mediators and cytokines (e.g., tumor necrosis factor [TNF], interleukin [IL]-1) that destroy the joint and formation of antibodies directed against joint-specific and systemic autoantigens. Page 1119
Osteoporosis is a disease caused by demineralization of bone. What is the clinical method of choice for diagnosing osteoporosis?
Dual-energy x-ray absorptiometry (DXA or DEXA) of the spine and hip Explanation: The clinical method of choice for bone mineral density (BMD) studies is dual-energy x-ray absorptiometry (DXA or DEXA) of the spine and hip. The other answers will not diagnose osteoporosis. Page 1114
When teaching a group of nursing students about rheumatic disorders, a nurse emphasizes which of the following important differences when caring for the older adult?
Risk for falls Explanation: The pain, stiffness, and muscle weakness affect daily life, often threatening independence and quality of life. Symptoms of the rheumatic diseases can also have an indirect effect on and even threaten the duration of life for older adults. The weakness and gait disturbance that often accompany rheumatic diseases can contribute to the likelihood of falls and fractures. Page 1135
A nurse is caring for a patient who has developed vasculitis as a result of a rheumatology disorder. Which of the following factors does the nurse expect to uncover in assessing this patient?
Ulcers of the lower extremities Explanation: Vasculitis, or inflammation of small and medium-sized arteries, manifest as ischemic areas in the nail fold and digital pulp that appears as brown spots. Ulcerations may occur in the lower extremities, particularly around the malleolar areas. Page 1121
An older adult client has recently been diagnosed with rheumatoid arthritis. The nurse should recognize the need to monitor the client's:
weight and nutritional status. Explanation: Anorexia is a common extra-articular symptom of RA. Consequently, there is a need to monitor the client's nutritional status and intake. Cognition, respiratory status and electrolytes are not typically affected. Page 1135
