Prep U Chapter 34: Assessment and Management of Patients with Inflammatory Rheumatic Disorders

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

-Decreased ventilation owing to lung scarring -Dysphagia owing to hardening of the esophagus -Dyspnea owing to fibrotic cardiac tissue Explanation: The changes within the body, although not visible directly, are vastly more important than the visible changes. The left ventricle of the heart is involved, resulting in heart failure. The esophagus hardens, interfering with swallowing. The lungs become scarred, impeding respiration. Digestive disturbances occur because of hardening (sclerosing) of the intestinal mucosa. Progressive kidney failure may occur.

A client is receiving treatment for an acute episode of gout with colchicine. The nurse is administering the medication every 2 hours. What should the nurse be sure the client communicates so that the drug can be temporarily stopped? Select all that apply. -Diarrhea -Tingling in the arms -Intestinal cramping -Increase in pain in the affected extremity -Nausea and vomiting

-Diarrhea -Intestinal cramping -Nausea and vomiting Explanation: Colchicine is administered every 1 or 2 hours until the pain subsides or nausea, vomiting, intestinal cramping, and diarrhea develop. When one or more of these symptoms occurs, the drug should be stopped temporarily. Tingling in the arms and increase in pain are not normal adverse reactions that are seen with this drug.

The nurse is creating a plan to assist an older adult to manage rheumatoid arthritis. Which areas will the nurse include in this plan? Select all that apply. -Exercise -Medication -Financial assistance -Psychological support -Modification of daily activities

-Exercise -Medication -Psychological support -Modification of daily activities

The nurse is creating a plan to assist an older adult to manage rheumatoid arthritis. Which areas will the nurse include in this plan? Select all that apply. -Exercise -Medication -Financial assistance -Psychological support -Modification of daily activities

-Exercise -Medication -Psychological support -Modification of daily activities Explanation: The various rheumatic disease conditions in the older adult pose unique challenges. These challenges relate to disability, cognitive changes, comorbid conditions, and diagnosis. Older adults would benefit from a self-management plan to assist with care needs. This plan should include information about exercise, medication, psychological support, and modification of daily activities. Financial assistance is not a part of the self-management plan for rheumatoid arthritis

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

-Fatigue -Pain -Alteration of self-concept Explanation: Clients with rheumatic diseases, which typically involve joints and muscles, experience problems with mobility, fatigue, and pain. Because of the limitations of the disease, clients often have an altered self-image and self-concept. Fluid and electrolyte imbalances are not typically associated with these types of diseases.

During a home visit, the nurse notes that a client with polymyositis has difficulty combing the hair and putting on socks and shoes. Which referrals will the nurse recommend for this client? Select all that apply. -Hospice -Pastoral care -Social services -Physical therapy -Occupational therapy

-Hospice -Pastoral care -Social services -Physical therapy -Occupational therapy Explanation: Clients with polymyositis may have symptoms similar to those of other inflammatory diseases. However, proximal muscle weakness is characteristic, making activities such as combing the hair, reaching overhead, and using stairs difficult. Therefore, the use of assistive devices may be recommended, and referral to physical therapy or occupational therapy may be warranted. There is no need for a referral to hospice, pastoral care, or social services.

A client with rheumatoid arthritis wants to try nonpharmacologic approaches to control the pain and stiffness. Which approaches will the nurse suggest that might improve the client's comfort and mobility? Select all that apply. -Golfing -Imagery -Massage -Self-hypnosis -Chiropractic adjustments

-Imagery -Massage -Self-hypnosis -Chiropractic adjustments

The nurse is performing an admission interview for a client with rheumatoid arthritis. Which finding will the nurse document as abnormal for this client? Select all that apply. -Pain -Nausea -Stiffness -Weakness -Joint swelling

-Pain -Stiffness -Weakness -Joint swelling Explanation: The most common symptom in the rheumatic diseases is pain. Other common symptoms include stiffness, weakness, and joint swelling in addition to limited movement and fatigue. Nausea is not a symptom of rheumatoid arthritis.

The nurse notes that a client is being treated for fibromyalgia. For which additional rheumatic conditions will the nurse analyze the client's health history? Select all that apply. -Ostearthritis -Psoriatic arthritis -Rheumatoid arthritis -Ankylosing spondylitis -Systemic lupus erythematosus

-Rheumatoid arthritis -Ankylosing spondylitis -Systemic lupus erythematosus Explanation: Fibromyalgia is a chronic pain syndrome that involves chronic fatigue, generalized muscle aching, stiffness, sleep disturbances, and functional impairment. Between 25% and 65% of clients with fibromyalgia have other rheumatic conditions such as rheumatoid arthritis (RA), ankylosing spondylitis (AS), and systemic lupus erythematosus (SLE). Osteoarthritis and psoriatic arthritis are not associated with fibromyalgia

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

-Safe exercise -Medication dosages and side effects -Assistive devices Explanation: The client with rheumatoid arthritis who is being discharged to home needs information on how to exercise safely to maintain joint mobility. Medication doses and side effects are always an essential part of discharge teaching. Assistive devices, such as splints, walkers, and canes, may assist the client to perform safe self-care. Narcotics are not commonly used, and there would be no reason for dressings

Which intervention should the nurse implement to manage pain for the client with rheumatoid arthritis? Select all that apply. -Support joints with splints and pillows. -Assist the client to develop a sleep routine. -Provide diversional activities. -Provide opportunities for the client to verbalize feelings. -Provide assistive devices for self-feeding.

-Support joints with splints and pillows. -Provide diversional activities. -Provide opportunities for the client to verbalize feelings.

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

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

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

-Use relaxation exercises. -Establish a set time to sleep every night. -Avoid caffeine before bedtime. -Create a quiet sleep environment.

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

-Weight loss -Decreasing alcohol intake -Avoiding purine-rich foods

As part of the assessment process for a client suspected of having gout, the nurse evaluated the client's serum uric acid levels. Select the value that is considered above the saturation point for crystal formation.

6.8 mg/dL (0.40 mmol/L) Explanation: Hyperuricemia, a serum uric acid concentration above 6.8 mg/dL (0.40 mol/L) can cause urate crystal deposition which can lead to gout.

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be?

Administering ordered analgesics and monitoring their effects Explanation: An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management her priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions don't not take priority over pain management.

A client with a history of gout experiences an attack every 2 to 3 months despite losing weight and stopping all alcohol intake. Which question will the nurse ask when assessing this client?

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

A health care provider orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis?

An above-normal anti-deoxyribonucleic acid (DNA) test Explanation: Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE.

A client with rheumatoid arthritis wants to participate in water aerobics classes for arthritis at the community center. Which statement will the nurse respond to this client?

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

A nurse is assigned to a client with polymyositis. Which expected outcome in the care plan relates to a potential problem associated with polymyositis?

"Client will exhibit no signs or symptoms of aspiration." Explanation: An expected outcome of no signs or symptoms of aspiration relates to symmetrical muscle weakness — a potential problem associated with polymyositis that may lead to speaking and swallowing problems. A client with a potential swallowing problem is at risk for inadequate nutrition and shouldn't be placed on a calorie-restricted diet; an expected outcome focusing on maintaining weight would be more appropriate than an outcome based on losing weight. Polymyositis doesn't affect bowel or bladder function or mental status; it isn't necessary to develop outcomes based on these parameters.

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

"It will get better and worse again." Explanation: The client demonstrates understanding of rheumatoid arthritis if he expresses that it's an unpredictable disease characterized by periods of exacerbation and remission. There's no cure for rheumatoid arthritis, but symptoms can be managed. Surgery may be indicated in some cases.

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain?

An exercise routine that includes range-of-motion (ROM) exercises Explanation: Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain

An older adult with rheumatoid arthritis limits going out with others because of the need to use a cane. Which response will the nurse make to this client?

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

The nurse is caring for a client with hypertension and scleroderma. Which medication will the nurse expect to be prescribed for this client?

Angiotensin-converting enzyme inhibitors Explanation: Treatment of scleroderma is mainly symptomatic and supportive. No medication regimen is effective in modifying the disease process in scleroderma, but various medications are used to treat organ system involvement. The use of angiotensin-converting enzyme inhibitors when there is kidney involvement has led to a substantial decrease in mortality from hypertensive kidney disease. Diuretics, vasodilators, and beta blockers are not used to treat hypertension caused by scleroderma.

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?

"Monitor your body temperature." Explanation: The nurse should instruct the client to monitor body temperature. Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation.

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?

"My finger joints are oddly shaped." Explanation: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?

"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Explanation: OA is a degenerative arthritis, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. OA may occur in one hip or knee and not the other, whereas RA commonly affects the same joints bilaterally. RA is more common in women; OA affects both sexes equally.

The nurse is teaching a newly diagnosed client about systemic lupus erythematosus(SLE). What statement by the client indicates the teaching was successful?

"The belief is that it is an autoimmune disorder with an unknown trigger." Explanation: Systemic lupus erythematosus is believed to be an autoimmune disorder but the triggering mechanism is not known. The disorder is more common in women than in men, most with the disorder in the 3rd or 4th decade of life. The disease is considered the "great imitator" because the clinical signs resemble many other conditions. SLE is a diffuse connective tissue disease that affects multiple body systems

An older adult with rheumatoid arthritis says exercise was not effective. Which response will the nurse make to learn the reason for the failure of this treatment approach?

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

The nurse is teaching a client about rheumatic disease. What statement best helps to explain autoimmunity?

"Your symptoms are a result of your body attacking itself." Explanation: In autoimmunity, the body mistakes its own tissue for foreign tissue and begins to attack it. Symptoms develop as the body destroys tissue. The body is in effect attacking itself. The other statements do not explain autoimmunity

A client is experiencing painful joints and changes in the lungs, heart, and kidneys. For which condition will the nurse schedule this client for diagnostic tests?

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

A client with rheumatoid arthritis is prescribed a disease-modifying antirheumatic drug (DMARD). Which information will the nurse explain regarding the purpose of this medication? Select all that apply. Control pain Induce remission Slow further tissue damage Suppress the immune response Alter progression of the disease

-Control pain -Induce remission -Slow further tissue damage -Suppress the immune response -Alter progression of the disease Explanation: DMARDs have the ability to suppress the autoimmune response; alter disease progression; and stop or decrease further tissue damage on the joints, cartilage, and organs. DMARDs have been found to halt the progression of bone loss and destruction and can induce remission. DMARDs are not used for pain management. Controlling the inflammation related to the disease process helps manage pain, but this is often a delayed response. Nonopioid medications are often used for pain management, especially early in the treatment program, until other measures can be instituted.

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

-Decreased ventilation owing to lung scarring -Dysphagia owing to hardening of the esophagus -Dyspnea owing to fibrotic cardiac tissue

A client with rheumatoid arthritis reports joint pain. What intervention is a priority to assist the client?

Nonsteroidal anti-inflammatory drugs Explanation: Nonsteroidal anti-inflammatory drugs are the mainstay of treatment for rheumatoid arthritis pain. They help to decrease inflammation in the joints. Heat, rather than ice packs, is used to relieve pain. Paraffin baths may also help. Surgery is reserved for joint replacement when the joint is no longer functional; it is not an intervention specific to relieving pain

A client is experiencing symptoms of giant cell arteritis (GCA). Which action will be taken to definitively diagnose this condition?

Obtain the results of a temporal artery biopsy. Explanation: The diagnosis of GCA can be difficult because of the lack of specificity of tests. However, in the case of GCA, biopsy of the temporal artery is the definitive diagnostic tool. The C-reactive protein can be used to diagnose GCA if other clinical findings are present. The response to corticosteroids may be considered as diagnostic for GCA and polymyalgia rheumatica. A markedly high erythrocyte sedimentation rate is a screening test but is not definitive for GCA.

The nurse is assessing a client with rheumatoid arthritis. The nurse knows that prolonged inflammation can cause compression of nerves. Which symptoms would accompany this level of involvement?

Paresthesias of both hands Explanation: The rheumatoid arthritis inflammatory process has been implicated in other disease processes. The nervous system is affected as synovial inflammation can compress adjacent nerves, causing neuropathies and paresthesias. Limited motion in the wrists and restricted movement in the tendons is caused by a breakdown of collagen and pannus formation which destroys cartilage and erodes the bone. This causes a loss of articular surfaces and joint motion and tendon and ligament elasticity and contractility is lost. Rheumatoid arthritis does not cause crepitus with movement.

The nurse knows that a patient who presents with the symptom of "blanching of fingers on exposure to cold" would be assessed for what rheumatic disease?

Raynaud's phenomenon Explanation: Blanching of fingers on exposure to cold is associated with Raynaud's phenomenon.

A client with systemic lupus erythematosus is prescribed belimumab. For which reason will the nurse question giving the client this medication?

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

A client is diagnosed with systemic lupus erythematosus (SLE). What is the most appropriate action for the nurse to take in order to evaluate the client's stage of disease?

Review the client's medical record. Explanation: The nurse evaluates the stage of SLE and plans appropriate interventions by reviewing the medical record and diagnostic findings of the client. The stage of the disease cannot be established by observing the client's gait, inspecting the client's mouth, or auscultating the client's lung sounds

A client is diagnosed with systemic lupus erythematosus (SLE). Which of the following would be most appropriate for the nurse to use to evaluate the client' s stage of disease?

Review the client's medical record. Explanation: The nurse evaluates the stage of SLE and plans appropriate interventions by reviewing the medical record and diagnostic findings of the client. The stage of the disease cannot be established by observing the client's gait, inspecting the client's mouth, or auscultating the client's lung sounds

The nurse is caring for a client with palindromic rheumatism. The nurse knows that this type of rheumatism can lead to which diagnosis?

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

Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues?

Scleroderma Explanation: Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. SLE is an immunoregulatory disturbance that results in increased autoantibody production. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries

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

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

The nurse is gathering objective data for a client at the clinic reporting arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. What does the nurse recognize this deformity as?

Swan neck deformity Explanation: A swan neck deformity is a hyperextension of the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. A Boutonnière deformity is a persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint. Ulnar deviation is when the fingers are deviating laterally toward the ulna. A rheumatoid nodule is a subcutaneous nodule

Which of the following disorders is characterized by an increased autoantibody production?

Systemic lupus erythematosus (SLE) Explanation: SLE is an immunoregulatory disturbance that results in increased autoantibody production. Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

A client asks the nurse how their rheumatoid arthritis is diagnosed. The nurse knows that which finding from diagnostic tests can be used to diagnose rheumatoid arthritis?

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

Which finding is consistent with the diagnosis of rheumatoid arthritis?

Cloudy synovial fluid Explanation: In a client with rheumatoid arthritis, arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement.

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find?

Elevated erythrocyte sedimentation rate Explanation: The erythrocyte sedimentation rate (ESR) may be elevated, particularly as the disease progresses. ESR shows inflammation associated with RA. Red blood cell count and C4 complement component are decreased. Serum protein electrophoresis may disclose increased levels of gamma and alpha globulin but decreased albumin.

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

Etanercept Explanation: Etanercept is an example of a tumor necrosis factor (TNF)-alpha inhibitor used to treat rheumatoid arthritis. Diclofenac and indomethacin are nonsteroidal anti-inflammatory drugs (NSAIDs). Celecoxib is a cyclooxygenase-2 (COX-2) inhibitor.

A nurse assesses a client in the health care provider's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?

Facial erythema, pericarditis, pleuritis, fever, and weight loss Explanation: An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE

A client cringes in pain when the nurse places the stethoscope over the upper back to assess breath sounds. On which condition will the nurse focus when assessing this client?

Fibromyalgia Explanation: The amplified pain experienced by clients with fibromyalgia is thought to be neurogenic in origin. The central nervous system's ascending and descending pathways that regulate and moderate pain processing function abnormally, causing amplification of pain signals. Stimulation that may not normally elicit pain, such as touching with a stethoscope, may cause pain. The pain of liver disease is typically felt in the right upper abdomen. The pain of gallbladder disease is referred to the upper right shoulder blade. Ankylosing spondylitis does not cause pain of the upper back

A client who has been diagnosed with osteoarthritis asks if he or she will eventually begin to notice deformities in the hands and fingers as the condition progresses. Which concept should the nurse include in the response?

Hand and finger deformities are associated with the development of rheumatoid arthritis. Explanation: The nurse should explain to the client that joint deformities occur with rheumatoid arthritis, not osteoarthritis. Osteoarthritis typically follows a pattern of cartilage destruction and increased pain. The nurse is part of the interdisciplinary health care team and is capable of answering the client's questions about the typical progression of disease

Which assessment suggests to the nurse that a client with systemic lupus erythematous is having renal involvement?

Hypertension Explanation: Hypertension is suggestive of renal damage in the client with systemic lupus erythematous

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

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

Which points should be included in the medication teaching plan for a client taking adalimumab?

It is important to monitor for injection site reactions. Explanation: It is important to monitor for injection site reactions when taking adalimumab. The medication is injected subcutaneously and must be refrigerated. The medication should be withheld if fever occurs. (used for rheumatoid arthritis)

A client has a serum study that is positive for the rheumatoid factor. What will the nurse tell the client about the significance of this test result?

It is suggestive of rheumatoid arthritis. Explanation: Rheumatoid factor is present in about 70% to 80% of patients with rheumatoid arthritis, but its presence alone is not diagnostic of rheumatoid arthritis, and its absence does not rule out the diagnosis. The antinuclear antibody (ANA) test is used to diagnose Sjögren's syndrome and systemic lupus erythematosus.

A client has a history of osteoarthritis. Which signs and symptoms should the nurse expect to find on physical assessment?

Joint pain, crepitus, Heberden's nodes Explanation: Clinical findings for osteoarthritis include joint pain, crepitus, Heberden's nodes (bony growths at the distal interphalangeal joints), Bouchard's nodes (growths involving the proximal interphalangeal joints), and enlarged joints. The joint pain occurs with movement and is relieved by rest. As the disease progresses, pain may also occur at rest. Bouchard's nodes involve the proximal interphalangeal joints. Hot, inflamed joints rarely occur in osteoarthritis. Tophi are deposits of sodium urate crystals that occur in chronic gout — not osteoarthritis. Swelling, joint pain, and tenderness on palpation occur with a sprain injury.

A client with degenerative joint disease asks the nurse for suggestions to avoid unusual stress on the joints. Which suggestion would be most appropriate?

Maintain good posture. Explanation: The nurse needs to remind the client with degenerative joint disease to maintain good posture. While the client need not maintain complete bed rest, performing aerobic exercises is not advisable as it may place undue stress on the joint worsening the condition. Shifting weight from one foot to the other does not help avoid unusual stress on a joint.

Which joint is most commonly affected in gout?

Metatarsophalangeal Explanation: The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of clients); this is referred to as podagra. The wrists, fingers, and elbows are less commonly affected. The tarsal area, ankle, and knee are not the most commonly affected in gout.

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

Methotrexate Explanation: Methotrexate is a DMARD that reduces the amount of joint damage and slows the damage to other tissues as well. Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID). Methylprednisolone is a steroid to reduce pain and inflammation and slow joint destruction. Mercaptopurine azathioprine is a cytotoxic drug.

The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care?

increased fatigue Explanation: Fatigue is common with rheumatoid arthritis. Finding a balance between activity and rest is an essential part of the therapeutic regimen. The client is reporting being able to do ADLs and decreased joint pain. The client's weight gain of 2 pounds does not correlate with self-care problems

A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include?

located over bony prominence Explanation: Rheumatoid nodules usually are nontender, movable, and evident over bony prominences, such as the elbow or the base of the spine. The nodules are not reddened.

Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia

may feel as if their symptoms are not taken seriously. Explanation: Because clients present with widespread symptoms that are often vague in nature, health care providers may misdiagnose them. Clients feel as though people are not listening to them. Nurses need to provide support and encouragement. Symptoms of disease vary from client to client and respond to different treatments. Clients do not lose their ability to walk

A diet plan is developed for a client with gouty arthritis. What should the nurse advise the client to limit the intake of?

organ meats Explanation: Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, chocolate, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis.

The client asks the nurse about types of exercise that do not stress the joints. What exercise will the nurse include in the teaching plan?

tai chi Explanation: T'ai chi is low impact, so this is the best exercise for low joint impact. Jogging, weight lifting, and running on a treadmill are high-impact, jarring types of exercise.

The client with an inflamed knee scheduled to have an arthrocentesis asks the nurse what the synovial fluid will look like. What is the best response by the nurse?

The fluid will be milky, cloudy, and dark yellow. Explanation: An arthrocentesis shows abnormal synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement.

The nurse is caring for a client who is being treated for fibromyalgia. What intervention will best assist the client to restore normal sleep patterns?

Tricyclic antidepressants Explanation: Tricyclic antidepressants and sleep hygiene measures are used to improve or restore normal sleep patterns in clients with fibromyalgia. Increasing activity during the day or using range-of-motion exercises will not increase the client's ability to sleep. Narcotics are generally not needed for pain control with this disorder

A client has been living with rheumatoid arthritis (RA) for several years. Which diagnostic test will the nurse prepare the client for to determine the progression of the disease?

X-ray Explanation: Plain x-ray is the most common radiographic study used to track disease progression as it is inexpensive, reliable, and reproducible. MRI may be used to detect erosions not visible on x-ray or ultrasound. CT scan is not routinely used to track the progression of RA. Ultrasound might be used to establish a baseline for joint evaluation however is not used to track progression of the condition.

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

aspirin Explanation: Salicylates like aspirin may have side effects such as tinnitus, gastric intolerance and bleeding. While celecoxib, methotrexate, and hydroxychloroquine have GI upset effects, the tinnitus is unique to aspirin.

A nurse is caring for a client with a warm and painful toe from gout. What medication will the nurse administer?

colchicine Explanation: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The health care provider orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide is a diuretic; it is not used to relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it is not used to treat gout.

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

colchicine Explanation: Colchicine is prescribed for the treatment of an acute attack of gout.

A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to:

combat inflammation. Explanation: Corticosteroids are used to combat inflammation in a child with SLE. To prevent infection, the physician would order antibiotics. Aspirin is used to prevent platelet aggregation. Diuretics, not corticosteroids, promote diuresis

A client is being treated for hyperuricemia. Part of the treatment strategy is for the client to avoid contributing factors whenever possible. Which activities might bring on an acute attack?

eating organ meats and sardines Explanation: During an acute attack, high-purine foods are avoided, including organ meats, gravies, meat extracts, anchovies, herring, mackerel, sardines, and scallops. The other listed factors do not worsen attacks

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

hydroxychloroquine Explanation: The DMARD hydroxychloroquine is associated with visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. The nurse should emphasize the need for ophthalmologic examinations every 6-12 months. Azathioprine, diclofenac, and cyclophosphamide do not have visual changes as a side effect

A client is recovering from an attack of gout. What will the nurse include in the client teaching?

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