Rheumatoid Arthritis, Gout, and Systemic Lupus Erythematosus (Practice Questions ONLY)

Pathophysiology of gout

-metabolic defect of uric acid -increased purine metabolism -inflammation of joint -untreated hyperuricemia leads to development of tophi -untreated gout may cause nephropathy/stone which can cause renal damage

High risk for osteoarthritits

-morbidly obese -long distance runners -weight lifters -soccer players

Primary Osteoarthritis

-most common in older age groups -d/t wear and tear on articular cartilage over time

Early symptoms of Rheumatoid Arthritis

-myopathy -fatigue -weight loss -malaise -affects proximal finger joints, wrists, feet, knees, shoulders -pain -tendon crepitus

NSAIDS

-non-steroidal anti-inflammatory drugs (ex. ibuprofen) -pharmacological management of osteoarthritis -celebrix, motrin, volaten, indocin, relafen, naprosyn, daypro, feldene -used when ASA not tolerated -side effects:GI irritation, ulceration, bleeding, renal toxicity give with food

Uric Acid

-normal blood levels: male- 4.5mg/100mL; female-3.5/100mL -in gout levels are >6mg/100mL

Risk Factors of Gout

-obesity -type IV hyperlipoprotenemia -impaired glucose tolerance -hypertension -ischemic heart disease

Incidence of rheumatoid arthritis

-occurs in women 3:1 -peak onset 30-50 years

Raynaud's

-pallor - the digits turn white -tissue oxygenation drops -the digits turn blue -finally vessels dilate- color turns red w/ flushing of digits

The nurse is caring for a middle-aged patient diagnosed with rheumatoid arthritis. Which patient statement requires further assessment for unproductive coping strategies?

"My husband is getting used to having sex only once a month."

Antimalarial agents

-pharmacological management of Rheumatoid Arthritis -decreases inflammation affecting production of inflammatory proteins -hydroxychloroquine -chloroquine

A patient with rheumatoid arthritis is prescribed hydroxychloroquine for joint and muscle pain. Which statements should the nurse include in the teaching?

"You should report any sign of blurred vision or headache."

Corticosteroids

-pharmacological management of Rheumatoid Arthritis -prednisone -decreases inflammation -does not halt joint destruction -side effects: poor wound healing, infection, osteoporosis

Osteoarthritis

-degenerative joint disease

A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should thennufse identify as risk factors for this disease? (SATA) a. Diuretic use b. Obesity c. Deep sleep deprivation d. Depression e. Cardiovascular disease

A, B, E

A nurse is working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint swelling and tenderness. Which of the following findings should the nurse expect? (SATA) a. Recent influenza b. Decreased range of motion c. Hypersalivation d. Increased blood prssure e. Pain at rest

A, B, E

A patient is admitted with life-threatening RA. What class of medications should be prescribed ASAP?

ANTINEOPLASTIC MEDICATIONS

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." c. "Pregnancy and breast-feeding are not affected by MTX." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects."

ANS: A, B, D, E MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.

30. An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

ANS: B This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the client's red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The client's white blood cell count is normal, so avoiding infection is not the priority

1. The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

ANS: B, C RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.

7. A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctly matched? (Select all that apply.) a. Allopurinol (Zyloprim) - Acute gout b. Colchicine (Colcrys) - Acute gout c. Febuxostat (Uloric) - Chronic gout d. Indomethacin (Indocin) - Acute gout e. Probenecid (Benemid) - Chronic gout

ANS: B, C, D, E Acute gout can be treated with colchicine and indomethacin. Chronic gout can be treated with febuxostat and probenecid. Allopurinol is used for chronic gout.

4. The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Felty's syndrome c. Joint deformity d. Low-grade fever e. Weight loss

ANS: B, C, E Late manifestations of RA include Felty's syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

Before administering prednisone IV push to a middle-aged adult with rheumatoid arthritis (RA), the nurse notes that the patient's random blood glucose level is 139. Which action is most important for the nurse to take?

Administer the prescribed prednisone on schedule.

8. A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower siderail on the affected side. d. Remind the client to do quad-setting exercises.

ANS: C Because the client's leg is strapped into the CPM, if it falls off the bed due to movement, the client's leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

1.A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

ANS: C Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.

8. The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Collaborate with a registered dietitian for appropriate foods. b. Inspect the skin and note any areas of ulceration. c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating.

ANS: C, D, E The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynaud's phenomenon. The UAP can adjust the room temperature for the client's comfort. Keeping the sheets off the feet will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can remind the client of this once he or she has been taught. The other actions are performed by the registered nurse.

10. A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important? a. Administering pain medication before transport b. Answering any last-minute questions by the client c. Ensuring the family has directions to the facility d. Providing a verbal hand-off report to the facility

ANS: D As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority.

12. A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the client's chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

ANS: D Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.

27. The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse? a. Checking to see if the machine is working b. Keeping controls in a secure place on the bed c. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal

ANS: D For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.

Which drug is an interleukin-1 (IL-1) receptor antagonist?

Anakinra

A client with possible osteoarthritis is scheduled for a synovial fluid analysis. The nurse should explain to the client that this diagnostic test is being completed for which​ reason? A. To rule out inflammatory arthritis and gout B. To identify irregular joint space narrowing C. To evaluate for increased density of subchondral bone D. To determine the extent of joint damage

Answer: A ​Rationale: Joint fluid analysis is used to detect​ inflammation, bacteria, and uric acid crystals to rule out inflammatory arthritis and gout. This test will not provide information on the extent of the joint damage. This test cannot identify the amount of joint space that has narrowed. This test cannot evaluate bone density.

Which assistive device should the nurse recommend to a client with osteoarthritis​ (OA) of the​ hands? (Select all that​ apply.) A. Handrails B. Reacher device C. Electric can opener D. Zipper hook E. Large-handled toothbrush

Answer: C, D, E ​Rationale: Zipper​ hooks, electric can​ openers, and​ large-handled toothbrushes can be helpful for clients with OA of the hands. Handrails can be useful for clients with OA of the hips. Reacher devices can be helpful for clients with OA of the shoulders.

Your patient with lupus (SLE) comes in for routine blood work. She mentions that she is planning a trip next weekend to Key West, FL with her and her husband. She is most excited to be in the sun all weekend. Based on this information, what should you tell your patient?

As a patient with lupus SLE it is very important that she not remain in the sun for prolonged periods of time and if she will be in the sun she needs to wear long sleeves, a wide brim hat and SPF 30 sun block. This is to avoid exacerbations of her lupus

A nurse is caring for a client who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose this disease? (SATA) a. Urinalysis b. Erythrocytes sedimentation rate (ESR) c. BUN d. Antinuclear antibody (ANA) tiger e. WBC count

B, D, E

A patient with rheumatoid arthritis is experiencing articulate involvement. The nurse recognizes these characteristic changes include (SATA) a. Bamboo-shaped fingers b. Metatarsal head dislocation in feet c. Non inflammatory pain in large joints d. Asymmetric involvement of small joints e. Morning stiffness lasting 60 minutes or more

B, E

Which condition is the consequence of pannus formation in a patient with rheumatoid arthritis?

Bony ankylosis

Periungual Lesions

Brownish lesions that appear near the nail bed. This indicates vasculitis (inflammation of the blood vessels)

Which nutritional supplements are recommended for patients with rheumatoid arthritis (RA)? Select all that apply.

Calcium Fish oil capsules Gamma-linolenic acid

The nurse reviews the chest x-ray report of a patient who is a coal miner and notes rheumatoid nodules in the lungs. The nurse also notes that the lung biopsy report revealed severe inflammation and fibrosis of the lung. Which complication does the nurse suspect in the patient?

Caplan's syndrome

Which syndrome is characterized by the presence of rheumatoid nodules in the lungs?

Caplan's syndrome

Synovitis

Chronic inflammation, synovial hypertrophy, effusion

Methotrexate (Rheumatrex) (MTX) (Folex) (meth-o-trex-ate)

Class: immunosuppressant, Indication: slows the progression of RA Adverse Reactions: decreased WBCs and platelets, increase in creatinine and liver enzymes Nursing Assessment: this is a slow-acting medication, takes 4-6 weeks to reach effectivity Patient Teaching: Monitor CBC with differential, liver and renal function, and uric acid levels prior to and frequently during therapy.

A patient with arthritis is prescribed an oral immunosuppressive agent. After 10 days, the patient developed hemorrhagic cystitis. What might be the immunosuppressive agent prescribed to the patient?

Cyclophosphamide

You suspect that you patient may have lupus. What tests should be ordered to determine this?

ESR, ANA, CBC, Skin biopsy

The nurse is explaining the clinical manifestations of joint involvement of rheumatoid arthritis with a nursing student. What is the best way to describe a Baker's cyst?

Enlarged popliteal bursae behind the knee

Which drug can be administered subcutaneously to a patient with rheumatoid arthritis (RA)?

Etanercept

True or False: RA flare ups are most prevalent in the summers months.

False, mostly prevalent in the winter months

True or False: A decreased WBC count is consistent with the inflammatory response related to RA.

False; a increased WBC is consistent

Which syndrome is associated with leukopenia in a patient with rheumatoid arthritis?

Felty's syndrome

Which anti-rheumatoid drug may increase the risk of opportunistic infections in patients?

Golimumab

Which biologic is approved for administration once a month for patients with rheumatoid arthritis and psoriatic arthritis?

Golimumab

A patient with suspected rheumatoid arthritis had an arthrocentesis. Which components present in the synovial fluid would indicate rheumatoid arthritis? Select all that apply

Immune complex Inflammatory cells Rheumatoid factor

You are assessing a patient and notice that there are more periungual lesions present on the nail bed than there were the day before. What does this increase indicate?

Increase vasculitis (inflammation of the blood vessels) which can lead to ulcerations

Which are the early manifestations of rheumatoid arthritis? Select all that apply.

Inflammation Low-grade fever

Which biological response modifier may cause chest pain and difficulty breathing during infusion?

Infliximab

Which drug is contraindicated for a patient with rheumatoid arthritis and multiple sclerosis?

Infliximab

Which characteristic is associated with gel phenomenon?

Morning stiffness

Which is a late manifestation of rheumatoid arthritis?

Morning stiffness

Lupus affects which population the most?

Mostly women; women of colored are far more affected as well

Your RA patient has been on an aspirin regimen to treat his RA. The aspirin is no longer effective. What would be the next category of drugs prescribed to treat his RA?

NSAIDs

While caring for a patient with rheumatoid arthritis, the nurse finds that the patient has a single hot, swollen, and painful wrist joint. Which is the best nursing intervention for this patient?

Notifying the primary health care provider

Which arthroplasty surgeries are commonly performed in patients with rheumatoid arthritis (RA)? Select all that apply.

Phalangeal arthroplasty Metatarsal arthroplasty Metacarpal arthroplasty

Which parameters should be assessed when etanercept and methotrexate are given as combination therapy in patients with rheumatoid arthritis? Select all that apply.

Platelet count Serum bilirubin Serum creatinine

After reviewing the prescription list of a patient with rheumatoid arthritis, the nurse advises calcium supplements. Which drug on the patient's prescription list requires calcium supplements to prevent side effects?

Prednisone

A female patient with severe RA is taking MTX. She comments that she is trying to get pregnant. What advice should you tell this patient?

Pregnancy is not recommended while taking MTX because it causes birth defects and to consult her HCP.

Your patient is admitted complaining of stiff joints in the morning for several weeks. You administer the prescribed aspirin and the patient feels better within 1 hours. What do you suspect the patient has?

RA

You patient has just been diagnosed with SLE and you are teaching your patient about toiletries to use with this condition. What products would you tell the patient to avoid or recommend?

Recommend mild soaps (ex: Ivory) and applying lotions after bathing, avoid harsh perfumed substances and overly drying substances like powders.

Which condition is associated with the presence of HLA-B27?

Reiter's syndrome

Which anti-rheumatic drugs are associated with allergic response after administration? Select all that apply.

Rituximab Abatacept Adalinumab

A patient has Raynaud's phenomenon, dysphagia, poor skin tugor, contractures, periungual lesions around the nail bed, and hypoactive bowel sounds. What autoimmune disorder does this patient have.

Scleroderma

Chronic rheumatoid arthritis (RA) can manifest as one of several associated syndromes. Which of the following is the most common in advanced RA?

Sjögren's syndrome

The nurse gives an intravenous infusion of infliximab to a patient with rheumatoid arthritis. The patient reports shortness of breath, chest discomfort, and has a heart rate of 110 beats per minute. Which nursing interventions are beneficial in this situation? Select all that apply.

Slowing the IV rate Discontinuing the therapy Notifying the primary health care provider

GOUT

Swollen, red, acutely painful great toe joint

Which antirheumatic drug acts by inhibiting tyrosine kinase?

Tofacitinib

True of False: The more advanced RA becomes the higher the erythrocyte sedimentation rate (ESR).

True

True or False: Alopecia is a common in patients with Lupus.

True

Which instructions for joint protection does the nurse recommend for a patient with a connective tissue disease? Select all that apply.

Use long-hangled devices such as a reacher Use adaptive devices such as Velcro closures

The nurse is teaching safety measures to a patient with rheumatoid arthritis who is on methotrexate therapy. Which statements should the nurse include? Select all that apply.

You should avoid crowded places You should avoid alcoholic beverages You should take folic acid supplements

Rheumatoid Arthritis (RA)

a chronic, progressive, systemic inflammatory autoimmune disease that mostly affects synovial joints

Pancytopenia

a decrease of all cel types

Hydroxychloroquine (Plaquenil)

a drug that decreases the absorption of UV light by the skin and therefore decreases the risk for skin lesions. it is important to receive an eye exam before taking this drug and to get one every six months after taking this drug

Synovectomy

a procedure to remove inflamed synovial fluid from joints

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."

c. "It is important to start methotrexate early to decrease the extent of joint damage."

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

c. Anti-Smith antibody (Anti-Sm)

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).

d. hydrochlorothiazide (HydroDIURIL).

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.

d. social isolation related to embarrassment about the effects of SLE.

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

d. the production of a variety of autoantibodies directed against components of the cell nucleus.

Would a decrease or increase in WBC count indicate Felty's syndrome?

decreased WBC count

Xerostomia

dry mouth

Effusions

joint swelling with fluid

A patient is admitted complaining of joint pain. You perform a physical inspection of the patient and note Heberden's nodes and severe weight loss. Does this physical assessment indicate early or late stage RA?

late stage RA

Felty's syndrome

less commonly observed in RA, enlarged liver and spleen

What are late manifestations of RA?

progressively inflamed and painful joints, morning stiffness, joints are soft and puffy

What is the leading cause of death in scleroderma patients?

renal failture

Caplan's syndrome

rheumatoid nodules in the lungs

Sjögren's syndrome

seen in advanced RA, is a combination of dry eye, dry mouth, and dry vagina in women

SLE

systemic lupus erythematosus

Butterfly Rash

the major skin manifestation of Lupus

Pannus

vascular granulation tissue composed of inflammatory cells, erodes the cartilage and eventually the bone

Which gender is mostly effected by RA?

women, young to middle-aged

Pathophysiology of Rheumatoid Arthritis (4 stages)

-1- joint inflammation and production of excess synovial fluid -2- formation of pannus (granulation inflammatory tissue) -3- tough, fibrous connective tissue replaces pannus -4- fibrous tissue calcifies

Rheumatoid Arthritis Prognosis

-10% improve -60% intermittent (slowly worsening) -20% severe joint erosion (multiple surgery) -10% completely disabled -50% too disabled to work 10 years after disease onset

Rheumatoid Arthritis Pharmacological Management

-ASA -NSAIDS -antimalarial agents -gold salts -immunosuppressive -cytotoxic agents -corticosteroids -adjunctive therapy

Pharmacologic Management of SLE

-ASA, NSAIDs -antimalarial drugs -corticosteroids (for severe, life threatening manifestations) -cytotoxic agents

Prevent Acute Attack

-Avoid: alcohol, dehydration, high purine food, high fat food, medications that increase UA, rapid weight loss/gains, intense exercise -Avoid beverages: tea, coffee, cocoa, chocolate, alcohol in any form -Avoid: liver, kidney, heart, sweetbreads, meat extracts, gravy, seafood -Avoud: peas, beans, spinach, lentils

Systemic Lupus Erythematosis (SLE)

-Lupus means "wolf" -Erythematosis means "redness" -facial rash looks like bite of a wolf -chronic inflammatory connective tissue damage -autoimmune origin

Impaired physical mobility

-active/passive ROM -isometric, progessive resistance -low impact aerobic exercise -analgesics before activity -plan rest periods -reach use of ambulatory aids (cane, walker, etc)

Clinical features of gout

-acute gouty arthritis -tenosynovitis -bursitis -tophaceous deposits -renal disease -urolithiasis- UA stones -joint inflammation/deformities

Pathophysiology of SLE

-antibodies form against own tissues -antigen/antibody complexes (suppress immunity, multiple organ dysfunction)

Diagnostic Tests of SLE

-antinuclear antibody titer -anti DNA antibody test -elevated ESR -decreased serum complement levels -false positive VDRL -postive LE cell prep -CBC -UA -Renal function

Incidence of SLE

-approx 1 in 2000 -females 9:1 -all races affected

Symptoms of SLE

-arthalgia -arthritis -fever (>100) -Hypertension -Anemia -Kidney damage -pleuritis -pericarditis -psychological -butterfly rash -skin rashes -photosensitivity -alopecia -raynaud's -seizures -mouth/nose ulcers -weight loss -abdominal pain

Pharmacological management for osteoarthritis

-aspirin (ASA) -tylenol -NSAIDs -intra-articular corticosteroid injections

Four stages of gout

-asymptomatic hyperuricemia -acute gouty attacks -asymptomatic inter-critical period -tophaceous gout with tophi in joints

Pharmacological management of Gout

-based on premise hyperuricemia d/t overproduction or under excretion -NSAIDS -Analgesics -Avoid ASA -Colchicine -Uricosuric agents -corticosteroids

Systemic Lupus Erythematosus (DLE)

-body develops antibodies against own normal tissue -affects many parts of body -manifestations of SLE very damaging -unpredictable course -no two patients are alike

Heberden's Nodes

-bone spurs over DIP joints on dorsum of fingers -pea size knobs near joints

Uric Acid Deposits

-bursae -most common in great toe -ankles and knees are next most common -anywhere in body (vocal cords, spinal cord, ears, kidneys)

Pathophysiology of Osteoarthritis

-cartilage, which cushions joint surfaces breaks down -bones rub together, joints lose shape and alignment -spurs (new bony growths) -loose cartilage (floating particles) -causes pain and loss of movement

Guot

-chronic disease -episodes of acute inflammation of affected joints -excrutiating pain and swelling of affected joints and surrounding tissues -metabolic disorder (elevated serum uric acid) -most likely to occur in big toe

Rheumatoid Arthritis

-chronic flares and remissions -progressive -systemic -affects all ages -inflammatory process -synovial joints primarily -often symmetric

Tophus

-chronic gout leads to deposit of urates into a chalky mass known as "tophus" -tophi destroy the joint and adjacent bone

Incidence of gout

-common in countries w/ a high living standard -environmental factors- diet plays a role -males 9:1 -incidence increases with age -females after menopause

Hand osteoarthritis

-common in elderly females -surgical treatment for pain and instability (may reduce pain, may improve decreased ROM, decreased pincer pain)

Three Types of Systemic Lupus Erythematosis (SLE)

-discoid lupus erythematosus (DLE) subacute cutaneous lupus (SCLE) -systemic lupus erythematosus -drug-induced systemic lupus erythematosus

Etiology of rheumotoid arthritis

-genetic link -endocrine factors -autoimmune -initiated by viral infection

Manifestations of osteoarthritis

-grating/crepitus on movement -joint pain -stiffness -swelling -decrease rom -instability -loss of function -joint enlargement (heberden's nodes, bouchard's nodes)

Inflammatory response in joints

-in synovial joints, only the synovium becomes inflamed -bone and cartilage respond to inflammation by destroying themselves

Diagnostic tests for Gout

-increased uric acid levels -increased WBC -increased ESR -analysis of synovial fluid -24 hours urine for UA -X ray

Rheumatoid Arthritis Joint Manifestations

-inflammation (slightly reddened, stiff, swollen tender, painful) -morning stiffness -joints may feel "soft of boggy" -muscle atrophy d/t disuse & pain -decreased ROM in joints -deformities (swan neck, ulnar deviation, boutonniere deformity)

Key features of Rheumatoid Arthritis

-insidious onset -bilateral -symmetrical -most common sites: fingers, toes, wrists, ankles, knees

Rheumatoid Arthritis X-Ray Findings

-joint space narrowing -peri-articular osteopenia -erosions

Factors Provoking Acute Gout Attack

-joint trauma -surgery -alcohol -unusual physical exercise -high protein diet, starvation -drugs-diuretics, dehydration -start uricosuric, allopurinol tx -severe incidental illness, fever

Most frequent joint affected by osteoarthritis

-knees -hips -lumbar -cervical vertebrae -fingers -wrists -big toe

Rheumatoid Arthritis Systemic Manifestations

-low grade fever -fatigue -weakness -anorexia -weight loss -paresthesias -round, moveable, non-tender, SC nodules -vasculitis -anemia -major organ involvement (heart, lungs, kidneys)

Gold Salts

-pharmacological management of Rheumatoid Arthritis -action unknown -remission in some clients -decreases body erosions -side effects: dermatitis, stomatitis, bone marrow depression

Treatment of SLE

-physical and emotional rest (8-10 hours/night) -physical activity encouraged as patient can tolerate -individualized exercise routine -protection from direct sunlight -healthful diet

Rheumatoid Arthritis Diagnostic Tests

-positive rheumatoid factor -elevated ESR -Increased antinuclear antibody titer -synovial fluid analysis (increased turbidity, decreased viscosity, increased proteins) -CBC (mild leukocytosis, anemia)

Treatment of gout

-prevention important to prevent joint damage -uricosuric agents may cause attack when initiated -avoid ASA - interferes w/ Uric acid excretion

Hyperuricemia and gout

-relationship unclear -not everyone with elevated uric acid levels develop gout -some patients w/ gout have normal uric avid levels

Discoid Lupus Erythematosus (DLE)

-skin rash only -20% of patients w/ SLE -patchy, crusty, sharply defined skin plaques that may scar -lesions on face / sun-exposed areas -patchy, bald areas on scalp -hypopigementation -hyper-pigmentation in older lesions -topical corticosteroids -antimalarial drugs -rarely progresses to systemic lupus erythematosus

Unicompartmental Knee Surgery

-smaller incision -less blood loss -lower morbidity -short recovery -less bone removed

Non-surgical treatment of osteoarthritis

-splints -analgesic meds- long term often needed -intra-articular injections - steroids -altered activity -ambulation aids -physical therapy

Rheumatoid Arthritis Treatment Goals

-stop synovitis -prevent deformities/ prevent worsening deformity -reconstruct -rehabilitate -decrease pain -improve appearance

Osteostomy

-surgical -incision into bone to realign affected joint -osteophytectomy - remove bony overgrowth -synovectomy- remove synovium

Arthrodesis

-surgical -joint fusion

Arthroscopy

-surgical -reconstruction or replacement -total joint replacement -arthroscope introduced into most often at the knee / small stab wound -damaged cartilage, loose cartilage and osteophytes removed -instruments inserted to view, repair ligaments, bones

Rheumatoid Arthritis Surgical Procedures

-synovectomy -tenocynovectomy -tendon surgery -arthroplasty -arthrodesis

Pathology of Rheumatoid Arthritis

-synovitis -destruction -deformity

Chronic joint inflamation

-synovium undergoes hyperplasia -destructive proliferation of synovium known as pannus -pannus spread and erodes cartilage and bone -large numbers of inflammatory cells present -production of auto-antibodies

Prognosis of SLE

-varies d/t organs involved and intensity of inflammatory reaction -most patients have normal lifespan with treatment -death is usually d/t renal failure or infections

Footwear for gout

-wearing of regular shoe becomes impossible over inflamed toe -common to see patient with a shoe on one foot and a slipper with a hole cut in the toe on the other

Prevention of Gout

-weight reduction -regular aerobic exercise -dietary changes -prescribed medications

Typical patient of acute attack

-young or middle aged male -wakes in early hours of morning with severe pain, usually in big toe -rapid onset, warmth, swelling, reddish, tender, fever -intense violent pain -subsides in 3-10 days -recurs over years

A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates understanding of the teaching? a. "I should limit my time to 10 minutes in the tanning bed." b. "I will apply powder to any skin rash." c. "I should use a mild hair shampoo." d. "I will inspect my skin once a month for rashes."

c. "I should use a mild hair shampoo."

A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following? 1. Development of a cataract. 2. Possible retinal degeneration. 3. Part of the disease process. 4. A coincidental occurrence.

2. Difficulty seeing out of one eye, when evaluated in conjunction with the client's medication therapy regimen, leads to the suspicion of possible retinal degeneration. The possibility of an irreversible retinal degeneration caused by deposits of hydroxychloroquine (Plaquenil) in the layers of the retina requires an ophthalmologic examination before therapy is begun and at 6-month intervals. Although cataracts may develop in young adults, they are less likely, and damage from the hydroxychloroquine is the most obvious at-risk factor. Eyesight is not affected by the disease process of rheumatoid arthritis.

After teaching a group of clients with osteoarthritis about using regular exercise, which of the following client statements indicates effective teaching? 1. "Performing range-of-motion exercises will increase my joint mobility." 2. "Exercise helps to drive synovial fluid through the cartilage." 3. "Joint swelling should determine when to stop exercising." 4. "Exercising in the outdoors year-round promotes joint relaxation."

2. Weight-bearing exercise plays a very important role in stimulating regeneration of cartilage, which lacks blood vessels, by driving synovial fluid through the joint cartilage. Joint mobility is increased by weight-bearing exercises, not range-of-motion exercises, because surrounding muscles, ligaments, and tendons are strengthened. Pain is an early sign of degenerative joint bone problems. Swelling may not occur for some time after pain, if at all. Osteoarthritic pain is worsened in cold, damp weather; therefore, exercising outdoors is not recommended year round in all settings.

The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit? 1. "I can use heat and cold as often as I want." 2. "With heat, I should apply it for no longer than 20 minutes at a time." 3. "Heat-producing liniments can be used with other heat devices." 4. "Ten to 15 minutes per application is the maximum time for cold applications."

3. Heat-producing liniment can produce a burn if used with other heat devices that could intensify the heat reaction. Heat and cold can be used as often as the client desires. However, each application of heat should not exceed 20 minutes, and each application of cold should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat, and vasodilation instead of vasoconstriction with cold.

On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for: 1. Limited motion of joints. 2. Deformed joints of the hands. 3. Early morning stiffness. 4. Rheumatoid nodules.

3. Initially, most clients with early symptoms of rheumatoid arthritis complain of early morning stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules.

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

c. C-reactive protein level

Scleroderma

A chronic connective tissue disease, similar to SLE, characterized by inflammation, fibrosis, and sclerosis

Systemic Lupus Erythematosus

A chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail

Biologics

A class of DMARDs (drugs that slow the progression RA). These drugs are very expensive and put the patient at risk for infection. Patients should avoid crowds and sick people.

Raynaud's phenomenon

A condition in which some areas of the body feel numb and cool in certain circumstances such as extreme cold or extreme stress White (blood flow is cut off), Red (blood flow returns), Blue (cyanosis due to low oxygen)

5. An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four siderails up. c. Restrain the client's hands. d. Use an abduction pillow.

ANS: D Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the client's mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation.

14. The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? a. Attends meetings of a book club b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints

ANS: A All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met.

2. A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a.Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

ANS: A All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

37. A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with the health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

ANS: A Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

15. A client is started on Etanercept (Enbrel). What teaching by the nurse is most appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site

ANS: A Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication. The other options are not appropriate for etanercept.

36. A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberden's nodules. What assessment technique is correct? a. Inspect the client's distal finger joints. b. Palpate the client's abdomen for tenderness. c. Palpate the client's upper body lymph nodes. d. Perform range of motion on the client's wrists.

ANS: A Herberden's nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the client's distal fingertips. These nodules are not found in the abdomen, lymph nodes, or wrists.

22. The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate? a. "Drink 1 to 2 liters of water each day." b. "Have 10 to 12 ounces of juice a day." c. "Liver is a good source of iron." d. "Never eat hard cheeses or sardines."

ANS: A Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from occurring. Citrus juice is high in ash, which can help prevent the formation of stones, but the value of this recommendation is not clear. Clients with gout should not eat organ meats or fish with bones, such as sardines.

25. A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the client's white blood cell count. b. Culture any drainage from the wound. c. Monitor the client's temperature every 4 hours. d. Use aseptic technique for dressing changes.

ANS: D Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.

24. A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started "acting up," especially both hips and knees. What action by the nurse is best? a. Assess the client for the presence of subcutaneous nodules or Baker's cysts. b. Inspect the client's feet and hands for podagra and tophi on fingers and toes. c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again.

ANS: A Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Baker's cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.

31. A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the client's leg.

ANS: A The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

33. A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the client's culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

ANS: A The nurse needs a more thorough understanding of the client's culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding

7. The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

ANS: A This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.

6. What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? a. Administer preoperative antibiotic as ordered. b. Assess the client's white blood cell count. c. Instruct the client to shower the night before. d. Monitor the client's temperature postoperatively.

ANS: A To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.

9. A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

ANS: A, B, D Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.

10. A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

ANS: A, B, D, E Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

6. The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.) a. Dry, scaly skin rash - Systemic lupus erythematosus (SLE) b. Esophageal dysmotility - Systemic sclerosis c. Excess uric acid excretion - Gout d. Footdrop and paresthesias - Osteoarthritis e. Vasculitis causing organ damage - Rheumatoid arthritis

ANS: A, B, E A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and paresthesias occur in rheumatoid arthritis.

The nurse is planning care for a client with osteoarthritis​ (OA). Which nursing diagnosis is a priority for the nurse to​ address? A. Lifestyle, Sedentary B. ​Pain, Chronic C. Skin​ Integrity, Impaired D. Family​ Processes, Interrupted

Answer: B ​Rationale: Chronic pain is the priority problem for the nurse to address when planning care for a client diagnosed with osteoarthritis. Sedentary lifestyle would be a concern because exercise can help to address OA but would not be a priority nursing diagnosis. Skin integrity and impaired family processes are not expected problems for the nurse to address when planning care for a client diagnosed with OA.

5. An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply an abduction pillow to the client's legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.

ANS: A, C, E The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurse's responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility.

11. A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

ANS: B All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.

3. The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. "Are you compliant with following the diabetic diet?" b. "Have you been taking glucosamine supplements?" c. "How much exercise do you really get each week?" d. "You're still taking your diabetic medication, right?"

ANS: B All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. "Compliant" is a word associated with negative images, and the client may deny being "noncompliant." Asking how much exercise the client "really" gets is accusatory. Asking if the client takes his or her medications "right?" is patronizing.

17. A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs c. Splints d. Wax dip

ANS: B Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

29. A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.

ANS: B The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

4. The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis d. Urinary tract infection

ANS: C Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.

34. A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best? a. "Let's ask the provider about increasing your pain pills." b. "Hold ice bags against your hands before quilting." c. "Try a paraffin wax dip 20 minutes before you quilt." d. "You need to stop quilting before it destroys your fingers."

ANS: C Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a "hot" or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.

26. A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management? a. "I can bend down to pick something up." b. "I no longer need to do my exercises." c. "I will not sit with my legs crossed." d. "I won't wash my incision to keep it dry."

ANS: C There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.

9. After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the client's pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the client's bladder or perform a bladder scan.

ANS: C With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.

After performing a physical​ assessment, the nurse suspects that a client is experiencing manifestations of osteoarthritis​ (OA). Which finding supports the​ nurse's suspicion?​ (Select all that​ apply.) A. Leg tremors B. Joint tenderness C. Reduced joint flexibility D. Crepitation E. Joint stiffness

Answer: B, C, D, E ​Rationale: Manifestations of OA include crackling​ sounds, or​ crepitation, with joint​ movement; joint stiffness and​ tenderness; and reduced joint flexibility. Leg tremors can be associated with multiple sclerosis or Parkinson disease.

Which health promotion activity supports a healthy lifestyle for clients with​ osteoarthritis? (Select all that​ apply.) A. Maintaining a normal weight B. Using proper body mechanics C. Using assistive devices as needed D. Increasing dietary intake of calcium E. Using soft chairs and recliners for rest

Answer: A, B, C ​Rationale: Maintaining a normal weight places less strain on the joints than carrying additional weight. Assistive devices such as grab​ bars, a shower​ chair, or​ long-handled grippers help the client to maintain an independent lifestyle in safety. Using proper body mechanics during activities reduces stress on joints. Although calcium intake is essential for preventing​ osteoporosis, especially in older​ adults, increasing daily calcium intake does not have a positive effect on OA. Chairs and mattresses should provide support and help to maintain normal body alignment. Soft chairs and recliners do not provide such support.

The nurse is providing teaching about home care for a client with osteoarthritis of the knees. Which information should the nurse​ include? (Select all that​ apply.) A. Installing handrails in the bathroom B. Using assistive devices to minimize stress placed on affected joint C. Taking pain medications as ordered D. Continuing activity with repetitive movement E. Encouraging heavy lifting to maintain muscle strength

Answer: A, B, C ​Rationale: Taking pain medications as ordered will assist with pain management and allow the client to participate in daily activities. Installing handrails in the bathroom is information that the nurse should include when educating a client to keep the client safer during activities of daily living at home. The nurse should educate the client on the importance of using assistive devices to minimize joint stress. The nurse should instruct the client to avoid repetitive movement and to avoid heavy​ lifting, because these actions will increase pain and joint degeneration and will not improve physical mobility.

Which is a common risk factor for​ osteoarthritis? (Select all that​ apply.) A. Overuse of joints from sports or strenuous activities B. Obesity C. Ingestion of large amounts of purine D. Autoimmune disorder E. Activities affecting​ weight-bearing joints

Answer: A, B, E ​Rationale: Common risk factors for osteoarthritis include​ obesity, overuse of joints from sports injuries or strenuous​ activities, and activities affecting​ weight-bearing joints. Rheumatoid arthritis is thought to be an autoimmune disorder. Ingestion of large amounts of purines is a risk factor for gout.

Which clinical manifestation of osteoarthritis​ (OA) should the nurse include when teaching about​ osteoarthritis? (Select all that​ apply.) A. Joint pain with activity B. Pain and stiffness at night C. Abrupt onset D. Mild fever E. Crepitus with movement of joint

Answer: A, B, E ​Rationale: Joint pain with​ activity, grating or crepitus noted with​ movement, and pain and stiffness with prolonged inactivity are general manifestations of OA. Mild fever is associated with rheumatoid​ arthritis, not OA. Osteoarthritis is a degenerative disease that develops over​ time, although symptoms may appear suddenly.

Which health promotion activity supports a healthy lifestyle for clients with​ osteoarthritis? (Select all that​ apply.) A. Maintaining a normal weight B. Using proper body mechanics C. Using assistive devices as needed D. Increasing dietary intake of calcium E. Using soft chairs and recliners for rest

Answer: A, C ​Rationale: Maintaining a normal weight places less strain on the joints than carrying additional weight. Assistive devices such as grab​ bars, a shower​ chair, or​ long-handled grippers help the client to maintain an independent lifestyle in safety. Using proper body mechanics during activities reduces stress on joints. Although calcium intake is essential for preventing​ osteoporosis, especially in older​ adults, increasing daily calcium intake does not have a positive effect on OA. Chairs and mattresses should provide support and help to maintain normal body alignment. Soft chairs and recliners do not provide such support.

Which surgical treatment should the nurse anticipate may be offered to clients with osteoarthritis who cannot be managed with traditional​ treatment? (Select all that​ apply.) A. Arthroplasty B. Serum hyaluronic acid C. Joint fusion D. Cortisone therapy E. Osteotomy

Answer: A, C, E ​Rationale: Arthroplasty,​ osteotomy, and joint fusion are all surgical interventions indicated for a client with osteoarthritis. Serum hyaluronic acid is a diagnostic blood test for knee osteoarthritis and is not a surgical treatment. Cortisone therapy is not a surgical​ treatment; it is injected into the inflamed joint.

The parents of a child newly diagnosed with juvenile osteoarthritis​ (OA) are concerned about their​ child's future ability to be disability free and remain independent. Which information should the nurse give the​ parents? (Select all that​ apply.) A. ​"Children may outgrow OA as they​ age." B. ​"OA in children is​ generalized, thus impacting all joints and increasing possible​ impairment." C. "The amount of disability will depend on how well the OA is managed as a​ child." D. "OA in children is usually​ idiopathic, making it difficult to determine how it will affect them as​ adults." E. ​"Children with OA are less likely to become​ disabled."

Answer: A, E ​Rationale: Children with OA are less likely to become disabled as adults and may outgrow the OA as they age. It is not likely that children with OA will be disabled as adults.

A​ 32-year-old client who has limited hip joint damage from osteoarthritis asks the nurse why an osteotomy is being performed rather than other procedures. Which response by the nurse provides the most accurate​ information? A. "This procedure is usually tried​ first; arthroplasty will be done later if this does not​ work." B. "This procedure can be done since you are young and healthy and your hip damage is​ limited." C. ​"This procedure prepares you for joint resurfacing and a total hip replacement later in​ life." D. "An osteotomy is much less invasive than all of the other​ procedures."

Answer: B ​Rationale: An osteotomy is performed to realign the joint or to shift the joint load toward areas of less cartilage damage. It is used instead of joint replacement surgery if the client is​ young, healthy, and damage is limited to only one side of the joint. This would provide the most accurate explanation to the client. It is not indicated as a surgery to necessarily be done first before an​ arthroplasty, nor to prepare the client for joint resurfacing surgery.

The nurse is teaching older adults with osteoarthritis​ (OA) actions to effectively manage chronic pain. Which recommendation should the nurse​ include? (Select all that​ apply.) A. Limiting isometric exercises to reduce strain on the joints B. Using firm support in chairs and mattresses to properly align the body C. Applying cool compresses to painful joints to reduce inflammation D. Teaching proper posture and good body mechanics for activities of mobility E. Encouraging resting painful joints

Answer: B, D, E ​Rationale: Chronic pain is frequently associated with OA. When joints are​ painful, they should be rested. The rest should be balanced with periods of​ activity, which will reduce joint stiffness. Using proper posture and good body mechanics places the body in proper alignment and offers the joints a neutral platform to perform range of motion activities. Firm chairs and mattresses assist the body in proper alignment. Heat should be applied to painful​ joints, which will increase joint mobility. Cool compresses may increase joint pain and will limit joint mobility. Isometric exercises strengthen muscle​ groups, which is important to provide additional strength in movement. Strong muscles will reduce strain on joints.

The nurse is teaching a class about the joints commonly affected by osteoarthritis​ (OA). Which joints should the nurse​ include? A. Ankles, feet, and spine B. Knees, feet, and spine C. Hands, knees, and hips D. Neck, shoulders, and ankles

Answer: C ​Rationale: Hands,​ knees, and hips are the most commonly affected joints of OA.​ Feet, spine,​ neck, shoulders, and ankles are not the most common locations.

The nurse is evaluating a client who has osteoarthritis (OA) of the hips and knees. Which statement by the client indicates progress toward meeting identified activity​ goals? A. "I've increased my running time to 30 minutes 3 times a week and use orthotics in my​ sneakers." B. "I have been completing the range of motion​ (ROM) exercises for all joints every other​ day." C. "I've been able to manage my pain so that I can independently complete my daily​ activities." D. "I limit the use of acetaminophen unless I absolutely need it to decrease my risk of liver​ toxicity."

Answer: C ​Rationale: Successful management of pain so that the client with OA can independently complete daily activities indicates progress toward an important goal. ROM should be done every day for all joints. Acetaminophen should be used regularly to help avoid severe pain from occurring. Running is a​ high-impact activity that can increase stress on joints.​ Low-activity aerobic​ exercise, not​ high-impact exercise, should be included in activity goals for the client with OA.

A client with osteoarthritis asks the nurse how to decrease wrist swelling. Which intervention should the nurse​ suggest? A. Increasing range of motion exercises for that joint to 3 times a day B. Applying a warm towel to the wrist joint 3 times per day for 20 minutes at a time C. Using compression cold packs to provide a deeper cold to the wrist joint D. Encouraging use of assistive devices during daily activities to decrease stress on the joint

Answer: C ​Rationale: The use of deep cold can best help to address swelling. Increasing ROM exercises to 3 times a day is not the best approach to decrease​ swelling; ROM helps to maintain flexibility of the joint. Heat decreases pain and increases​ flexibility; it does not address swelling. Assistive device use can decrease stress on the joint to possibly prevent​ swelling, but it would not be the best approach to address swelling once it has occurred.

A client diagnosed with localized idiopathic osteoarthritis​ (OA) asks the nurse what this means. Which response by the nurse provides the most accurate​ information? A. "Idiopathic describes OA overall while localized indicates that it affects one body joint​ only." B. "Idiopathic refers to the fact that the OA has already progressed significantly in one or two​ joints." C. "Idiopathic OA has no identifiable​ cause; when it is​ localized, it only affects one or two​ joints." D. ​"Idiopathic OA, as compared with secondary​ OA, is caused by some kind of underlying​ condition."

Answer: C ​Rationale: There are two types of​ OA, idiopathic and secondary. Idiopathic OA has no identifiable cause and can be further subdivided as localized or​ generalized, with localized indicating that the OA only affects one or two​ joints, so stating that it has no identifiable cause and is limited to one or two joints would be the most accurate response. Idiopathic OA is not due to an underlying condition. Idiopathic refers to​ cause, not progression of the disease. Idiopathic is not a term used in general for​ OA, nor does the term localized indicate that affected joints are either in the upper or lower torso.

The nurse is counseling a newly pregnant client with osteoarthritis​ (OA). Which information should the nurse​ include? A. "Pregnancy has no impact on OA if you keep your weight gain within the recommended​ limits." B. ​"You need to restrict your participation in​ low-impact aerobic​ exercises." C. "Your pain from the OA may increase due to the weight gain of​ pregnancy." D. "You may continue to take your prescription nonsteroidal​ anti-inflammatory drug without any risk of harm to the​ fetus."

Answer: C ​Rationale: Weight gain of pregnancy may increase the pain resulting from OA due to the increased stress on the​ joints; this would be important information to include. The impact of nonsteroidal​ anti-inflammatory drugs, such as celecoxib​ (Celebrex), on the fetus is​ unknown; the nurse would not tell the client that it is safe to use.​ Low-impact aerobic exercises are recommended for clients with OA. The recommended weight gain for pregnancy would not be changed due to the​ OA, nor is it valid to indicate that pregnancy will have no impact on the OA.

The nurse is teaching an older adult recently diagnosed with osteoarthritis​ (OA) about interventions to help maintain mobility of the joints. Which should the nurse​ include? A. Jogging three times a week B. Routine nonsteroidal​ anti-inflammatory drug​ (NSAID) use C. Glucosamine and chondroitin supplements D. Physical therapy

Answer: D ​Rationale: Physical therapy is particularly important for older adults with OA to help them maintain or improve joint mobility. NSAIDs should generally not be used by older adults due to the risks associated with their use. Older adults should use acetaminophen as a​ first-line drug and narcotics as a​ second-line choice. Jogging is a​ high-impact activity that could place more stress on the joints and would not be recommended. The utility of supplements has not been supported as​ effective; additionally, the use of glucosamine and chondroitin may increase the risk of bleeding.

The nurse is assessing an older adult who has osteoarthritis​ (OA). Which finding indicates the impact of​ OA? A. Sitting in a soft chair and not getting up to greet the nurse B. Requesting a dose of acetaminophen to address joint pain C. Asking the nurse to retrieve items from across the room D. Leaning on furniture while walking

Answer: D ​Rationale: When assessing the client with​ OA, the nurse should observe how the client moves and ambulates. Noting that the client leans on furniture while walking indicates possible issues related to the OA. Asking the nurse to retrieve items from across the​ room, requesting a dose of​ acetaminophen, and not getting up when the nurse arrives do not provide any direct observable data to indicate the possible impact of OA on the client.

A patient is admitted with hand and forearm edema and bilateral carpal tunnel syndrome. There was no trauma associated with the edema and the patient states they have not eaten anything irregular or performed any irregular activities. The patient does state that they have a familial history of connective tissue disease. What do you suspect the patient has?

Scleroderma, forearm edema is the first sign of this.

A patient with rheumatoid arthritis says to the nurse, "My eyes feel gritty." Further assessment reveals that the patient also has redness in the eyes and no tears. What does the nurse suspect in this patient?

Sjögren's syndrome

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."

a. "Tell me more about situations that are causing you stress."

A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? a. "You can experience morning stiffness when you get out of bed." b. "You can experience abdominal pain." c. "You can experience weight gain." d. "You can experience low blood sugar."

a. "You can experience morning stiffness when you get out of bed."

You patient has just been diagnosed with SLE and you are teaching your patient about signs and symptoms they should report immediately to their HCP. What signs and symptoms would you describe?

an elevated temperature or fever (could signify exacerbation) and rash

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."

b. "I will use sunscreen when I am outside."

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.

b. Administer varicella vaccine.

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.

b. Application of cold packs before exercise may decrease joint pain.

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

b. Elevated blood urea nitrogen (BUN)

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

b. Fexubostat

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) .

b. Suggest that the patient use over-the-counter (OTC) artificial tears.

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.

b. blood pressure.

Osteonecrosis

bone death caused by poor blood supply

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.

c. The patient takes one aspirin a day to prevent angina.

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.

c. The white blood cell (WBC) count is 1500/µL

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).

c. Use a footboard to hold bedding away from the toe.

An arthrocentesis is performed to assess the synovial fluid of a patient with advanced RA. What would this fluid look like?

cloudy or milky or dark yellow

A nurse is assessing a client who has a new diagnosis of SLE. Which of the following findings should the nurse expect? a. Weight gain b. Petechiae on thighs c. Systolic murmur d. Alopecia

d. Alopecia

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.

d. The patient sleeps with two pillows under the head.

It is important for patients to taking corticosteroids to take their medication at what time of day?

early in the morning before breakfast because this is the time when the body's natural corticosteroid level is the lowest

A patient is admitted complaining of joint pain. A series of tests are ordered and the results are as follows: elevated Erythrocyte Sedimentation Rate (ESR) levels, positive result on an ANA titer and C-reactive protein, low RBC count, joint inflammation, and red swollen joints. Do these lab results indicate early or late stage RA?

early stage RA

Which ethinc group of people is most affected by RA?

euro-americans

What types of food should patients with scleroderma avoid?

foods that stimulate gastric secretions such as spicy foods, caffeine, and alcohol

What are early manifestations of RA?

generalized weakness/fatigue, anorexia, low-grade fever, slightly reddened and stiff joints

What type of medication is given in combination with salicylates and NSAIDs to induce remission and decrease pain and inflammation?

gold salts

What does the word scleroderma mean?

hardening of the skin

You patient has just recently been diagnosed with lupus. What diet would you recommend to avoid exacerbation?

high vitamin and high iron, high protein is recommend only if you are sure there are no renal issues

Gel Phenomenon

morning stiffness in late RA

A client with osteoporosis needs education about diet and ways to increase bone density. Which of the following should be included in the teaching plan? Select all that apply. 1. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals. 2. Choose good calcium sources, such as figs, broccoli, and almonds. 3. Use alcohol in moderation because a moderate intake has no known negative effects. 4. Try swimming as a good exercise to maintain bone mass. 5. Avoid the use of high-fat foods, such as avocados, salad dressings, and fried foods.

1, 2, 3. A diet with adequate amounts of vitamin D aids in the regulation, absorption, and subsequent utilization of calcium and phosphorus, which are necessary for the normal calcification of bone. Figs, broccoli, and almonds are very good sources of calcium. Moderate intake of alcohol has no known negative effects on bone density but excessive alcohol intake does reduce bone density. Swimming, biking, and other non- weight-bearing exercises do not maintain bone mass. Walking and running, which are weight-bearing exercises, do maintain bone mass. The client should eat a balanced diet but does not need to avoid the use of high-fat foods.

Risk factors for osteoarthritis

-age (occurs when joint wears out) -females over 55 -males over 45 -obesity -repetitive joint overuse -trauma

Characteristics of Osteoarthritis

-degeneration -loss of articular cartilage in synovial joints -asymmetric joint space narrowing -osteophytes-bony spurs -non systemic changes -affects joints that support weight (like the knees) -most common type of arthritis -gradual insidious onset

X-ray changes in osteoarthritis

-joint space narrowing -osteophytes form -subchondral sclerosis -bony cysts develop -lateral joint deformity -collapse of central joint cortical bone

Secondary Osteoarthritis

-results from previously damaged cartilage -d/t trauma, inflammatory arthritis, gout, diabetes, genetic

Of the clients listed below, who is at risk for developing rheumatoid arthritis (RA)? Select all that apply. 1. Adults between the ages of 20 and 50 years. 2. Adults who have had an infectious disease with the Epstein-Barr virus. 3. Adults that are of the male gender. 4. Adults who possess the genetic link, specifically HLA-DR4. 5. Adults who also have osteoarthritis.

1, 2, 4. Rheumatoid arthritis (RA) affects women three times more often than men, between the ages of 20 and 55 years. Research has determined that RA occurs in clients who have had infectious disease, such as the Epstein-Barr virus. The genetic link, specifically HLA-DR4, has been found in 65% of clients with RA. People with osteoarthritis are not necessarily at risk for developing rheumatoid arthritis.

Which of the following statements should the nurse include in the teaching session when preparing a client for arthrocentesis? Select all that apply. 1. "A local anesthetic agent may be injected into the joint site for your comfort." 2. "A syringe and needle will be used to withdraw fluid from your joint." 3. "The procedure, although not painful, will provide immediate relief." 4. "We'll want you to keep your joint active after the procedure to increase blood flow." 5. "You will need to wear a compression bandage for several days after the procedure."

1, 2, 5. An arthrocentesis is performed to aspirate excess synovial fluid, pus, or blood from a joint cavity to relieve pain or to diagnosis inflammatory diseases such as rheumatoid arthritis. A local agent may be used to decrease the pain of the needle insertion through the skin and into the joint cavity. Aspiration of the fluid into the syringe can be very painful because of the size and inflammation of the joint. Usually a steroid medication is injected locally to alleviate the inflammation; a compression bandage is applied to help decrease swelling; and the client is asked to rest the joint for up to 24 hours afterwards to help relieve the pain and promote rest to the inflamed joint. The client may experience pain during this time until the inflammation begins to resolve and swelling decreases.

A client with osteoarthritis will undergo an arthrocentesis on his painful edematous knee. What should be included in the nursing plan of care? Select all that apply. 1. Explain the procedure. 2. Administer preoperative medication 1 hour before surgery. 3. Instruct the client to immobilize the knee for 2 days after the surgery. 4. Assess the site for bleeding. 5. Offer pain medication.

1, 4, 5. To prepare a client for an arthrocentesis, the nurse should tell the client that a local anesthetic administered by the physician will decrease discomfort. There may be bleeding after the procedure, so the nurse should check the dressing. The client may experience pain. The nurse should offer pain medication and evaluate outcomes for pain relief. Because a local anesthetic is used, the client will not require preoperative medication. The client will rest the knee for 24 hours and then should begin range-of-motion and muscle strengthening exercises.

2. A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which nursing diagnosis would be most appropriate? 1. Activity intolerance related to fatigue and pain. 2. Self-care deficit related to increasing joint pain. 3. Ineffective coping related to chronic pain. 4. Disturbed body image related to fatigue and joint pain.

1. Based on the client's complaints, the most appropriate nursing diagnosis would be Activity intolerance related to fatigue and pain. Nursing interventions would focus on helping the client conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the activity intolerance and increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may develop ineffective coping or body image disturbance as the disorder becomes chronic with increasing pain and fatigue.

After teaching the client with severe rheumatoid arthritis about prescribed methotrexate (Rheumatrex), which of the following statements indicates the need for further teaching? 1. "I will take my vitamins while I'm on this drug." 2. "I must not drink any alcohol while I'm taking this drug." 3. "I should brush my teeth after every meal." 4. "I will continue taking my birth control pills."

1. Because some over-the-counter vitamin supplements contain folic acid, the client should avoid self-medication with vitamins while taking methotrexate, a folic acid antagonist. Because methotrexate is hepatotoxic, the client should avoid the intake of alcohol, which could increase the risk for hepatotoxicity. Methotrexate can cause bone marrow depression, placing the client at risk for infection. Therefore, meticulous mouth care is essential to minimize the risk of infection. Contraception should be used during methotrexate therapy and for 8 weeks after the therapy has been discontinued because of its effect on mitosis. Methotrexate is considered teratogenic.

Which of the following statements indicates that the client with osteoarthritis understands the effects of capsaicin (Zostrix) cream? 1. "I always wash my hands right after I apply the cream." 2. "After I apply the cream, I wrap my knee with an elastic bandage." 3. "I keep the cream in the cabinet above the stove in the kitchen." 4. "I also use the same cream when I get a cut or a burn."

1. Capsaicin cream, which produces analgesia by preventing the reaccumulation of substance P in the peripheral sensory neurons, is made from the active ingredients of hot peppers. Therefore, clients should wash their hands immediately after applying capsaicin cream if they do not wear gloves, to avoid possible contact between the cream and mucous membranes. Clients are instructed to avoid wearing tight bandages over areas where capsaicin cream has been applied because swelling may occur from inflammation of the arthritis in the joint and lead to constriction on the peripheral neurovascular system. Capsaicin cream should be stored in areas between 59 ° F and 86 ° F (15 ° C and 30 ° C). The cabinet over the stove in the kitchen would be too warm. Capsaicin cream should not come in contact with irritated and broken skin, mucous membranes, or eyes. Therefore it should not be used on cuts or burns.

The client diagnosed with osteoarthritis states, "My friend takes steroid pills for her rheumatoid arthritis. Why don't I take steroids for my osteoarthritis?" Which of the following is the best explanation? 1. Intra-articular corticosteroid injections are used to treat osteoarthritis. 2. Oral corticosteroids can be used in osteoarthritis. 3. A systemic effect is needed in osteoarthritis. 4. Rheumatoid arthritis and osteoarthritis are two similar diseases.

1. Corticosteroids are used for clients with osteoarthritis to obtain a local effect. Therefore, they are given only via intra-articular injection. Oral corticosteroids are avoided because they can cause an acceleration of osteoarthritis. Rheumatoid arthritis and osteoarthritis are two different diseases.

A postmenopausal client is scheduled for a bone-density scan. To plan for the client's test, what should the nurse communicate to the client? 1. Request that the client remove all metal objects on the day of the scan. 2. Instruct the client to consume foods and beverages with a high content of calcium for 2 days before the test. 3. Inform the client that she will need to ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test. 4. Tell the client that she should report any significant pain to her physician at least 2 days before the test.

1. Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.

A physician orders a lengthy X-ray examination for a client with osteoarthritis. Which of the following actions by the nurse would demonstrate client advocacy? 1. Contact the X-ray department and ask the technician if the lengthy session can be divided into shorter sessions. 2. Contact the physician to determine if an alternative examination could be scheduled. 3. Provide a dose of acetaminophen (Tylenol). 4. Cancel the examination because of the hard X-ray table.

1. Shorter sessions will allow the client to rest between the sessions. Changing the physician's order to a different examination will not provide the information needed for this client's treatment. Acetaminophen is a nonopioid analgesic and an antipyretic, not an anti-inflammatory agent. Thus, it would not help this client avoid the adverse effects of a lengthy X-ray examination. Although the X-ray table is hard, there are other options for making the client comfortable, rather than canceling the examination.

The drug leflunomide is often used for pain management in patients with rheumatoid arthritis (RA). What is the drug's initial loading dose? Record your answer using a whole number. ___ mg

100

At which of the following times should the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? 1. At bedtime. 2. On arising. 3. Immediately after a meal. 4. On an empty stomach.

3. Drugs that cause gastric irritation, such as ibuprofen, are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will lead to gastric irritation. Taking the drug at bedtime with food may cause the client to gain weight, possibly aggravating the osteoarthritis. When the client arises, he is stiff from immobility and should use warmth and stretching until he gets food in his stomach.

A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care? 1. Relieving pain. 2. Preserving joint function. 3. Maintaining usual ways of accomplishing tasks. 4. Preventing joint deformity.

3. Maintaining usual ways of accomplishing tasks would be the lowest priority during the acute phase. Rather, the focus is on developing less stressful ways of accomplishing routine tasks. Pain relief is a high priority during the acute phase because pain is typically severe and interferes with the client's ability to function. Preserving joint function and preventing joint deformity are high priorities during the acute phase to promote an optimal level of functioning and reduce the risk of contractures.

After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which of the following, if stated by the client, would indicate the need for additional teaching? 1. Pushing with palms when rising from a chair. 2. Holding packages close to the body. 3. Sliding objects. 4. Carrying a laundry basket with clinched fingers and fists.

4. Carrying a laundry basket with clinched fingers and fists is not an example of conserving energy of small joints. The laundry basket should be held with both hands opened as wide as possible and with outstretched arms so that pressure is not placed on the small joints of the fingers. When rising from a chair, the palms should be used instead of the fingers so as to distribute weight over the larger area of the palms. Holding packages close to the body provides greater support to the shoulder, elbow, and wrist joints because muscles of the arms and hands are used to stabilize the weight against the body. This decreases the stress and weight or pull on small joints such as the fingers. Objects can be slid with the palm of the hand, which distributes weight over the larger area of the palms instead of stressing the small joints of the fingers to pick up the weight of the object to move it to another place.

Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? 1. Anemia. 2. Osteoporosis. 3. Weight loss. 4. Local joint pain.

4. Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain, unlike rheumatoid arthritis, which has systemic manifestation such as anemia and osteoporosis. Weight loss occurs in rheumatoid arthritis, whereas most clients with osteoarthritis are overweight.

The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods? 1. Proper body alignment. 2. Elevating the part. 3. Prone lying positions. 4. Positions of flexion.

4. Positions of flexion should be avoided to prevent loss of functional ability of affected joints. Proper body alignment during rest periods is encouraged to maintain correct muscle and joint placement. Lying in the prone position is encouraged to avoid further curvature of the spine and internal rotation of the shoulders.

A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate? 1. "You are probably exercising too much. Decrease your exercise to every other day." 2. "Tell the physician about your symptoms. Maybe your analgesic medication can be increased." 3. "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." 4. "Take a warm tub bath or shower before exercising. This may help with your discomfort."

4. Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.

The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?" Which of the following responses by the nurse would be most appropriate? 1. "It's the physician's prerogative to decide how to treat you. The physician has chosen what is best for your situation." 2. "Tell me more about your friend's arthritic condition. Maybe I can answer that question for you." 3. "That drug is used for cases that are worse than yours. It wouldn't help you, so don't worry about it." 4. "Every person is different. What works for one client may not always be effective for another."

4. The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the physician's prerogative to decide how to treat the client implies that the client is not a member of his or her own health care team and is not a participant in his or her care. The statement also is defensive, which serves to block any further communication or questions from the client about the physician. Asking the client to tell more about the friend presumes that the client knows correct and complete information, which is not a valid assumption to make. The nurse does not know about the client's friend and should not make statements about another client's condition. Stating that the drug is for cases that are worse than the client's demonstrates that the nurse is making assumptions that are not necessarily valid or appropriate. Also, telling the client not to worry ignores the underlying emotions associated with the question, totally discounting the client's feelings.

What is the usual prescribed dose for subcutaneous injection of adalimumab to treat symptoms of inflammatory arthritis? Record your answer using a whole number. ___ mg

40

What is the recommended daily dosage of vitamin D for patients taking chronic steroid therapy to prevent osteoporosis? Record your answer using a whole number. ___ mg

400

A nurse is reviewing the plan of care for a client who ha systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (SATA) a. Positive ANA titer b. Increased hemoglobin c. 2+ urine protein d. Increased serum C3 and C4 e. Elevated BUN

A, C, E

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

a. Blurred vision

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.

a. a warm bath followed by a short rest

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).

a. relief of joint pain.

A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenom. Which of the following findings should the nurse anticipate? a. Swelling of joints of the fingers b. Pallor of toes with cold exposure c. Feet that become reddened with ambulation d. Client report of intense feeling of heat in the fingers

b. Pallor of toes with cold exposure

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.

b. Suggest that the patient take a nap in the afternoon.

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.

b. The patient is trying to get pregnant before her disease becomes more severe.

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.

b. The patient's blood glucose is 165 mg/dL.

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.

c. Assess the nodules for skin breakdown or infection.

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.

c. self-administration of subcutaneous injections.

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.

d. avoid activities that require repetitive use of the same muscles and joints.