TEST 3

A nurse is planning patient education for a patient being discharged home with a diagnosis of rheumatoid arthritis. The patient has been prescribed antimalarials for treatment, so the nurse knows to teach the patient to self-monitor for what adverse effect? A) Tinnitus B) Visual changes C) Stomatitis D) Hirsutism

****Hydroxychloroquine B ANS: B Rationale: Antimalarials may cause visual changes; regular ophthalmologic examinations are necessary.

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.

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 interval. 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.

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.

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.

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

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

6. A client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This client has been diagnosed with which health problem? A. Rheumatoid arthritis (RA) B. Systemic lupus erythematosus (SLE) C. Osteoporosis D. Polymyositis

ANS: A Rationale: In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately form pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not involve pannus formation.

A nurse is working with a client with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the client is experiencing adverse effects of this drug? A. "I have this ringing in my ears that just won't go away." B. "I feel so foggy in the mornings and it takes me so long to wake up." C. "When I eat a meal that's high in fat, I get really nauseous." D. "I seem to have lost my appetite, which is unusual for me."

ANS: A Rationale: Tinnitus is associated with salicylate therapy. Salicylates do not normally cause drowsiness, intolerance of high-fat meals, or anorexia

A client has a diagnosis of rheumatoid arthritis, and the primary provider has now prescribed cyclophosphamide. The nurse's subsequent assessments should address which potential adverse effect? A. Bone marrow suppression B. Acute confusion C. Sedation D. Malignant hyperthermia

ANS: A Rationale: When admin immunosuppressive such as cyclophosphamide, the nurse should be alert to manifestations of bone marrow suppression and infection. Confusion and sedation are atypical adverse effects. Malignant hyperthermia is a surgical complication and not a possible adverse effect.

A client with a history of arthritis is being discharged to home after right wrist surgery, and the nurse reviews nonopioid pain relief measures. Which intervention(s) would best address the needs of this client? Select all that apply. A. Paraffin bath B. Nonsteroidal anti-inflammatory drugs (NSAIDs) C. Rolling walker D. Antiepileptic medications E. Splint or brace

ANS: A, B, E Rationale: Heat application helps relieve pain, stiffness, and muscle spasms. Paraffin baths (dips), which offer concentrated heat, are helpful to clients with wrist and small-joint involvement. Useful medications to control inflammation include NSAIDs (nonsteroidal anti-inflammatory drugs) and salicylates. Devices such as braces and splints ease pain by limiting movement.

A nurse is providing care for a client who has just been diagnosed with early-stage rheumatoid arthritis (RA). The nurse should anticipate the administration of which medication? A. Hydromorphone B. Methotrexate C. Allopurinol D. Prednisone

ANS: B Rationale: Once the diagnosis of RA is made, treatment should begin with either a nonbiologic or biologic disease-modifying antirheumatic drug (DMARD). Recommended treatment guidelines include beginning with the nonbiologic DMARDs (methotrexate, leflunomide, sulfasalazine) or hydroxychloroquine within 3 months of disease onset. Allopurinol is used to treat gout. Opioids are not indicated in early RA. Prednisone is used in unremitting RA.

A nurse is providing care for a patient who has a rheumatic disorder. The nurses comprehensive assessment includes the patients mood, behavior, LOC, and neurologic status. What is this patients most likely diagnosis? A) Osteoarthritis (OA) B) Systemic lupus erythematosus (SLE) C) Rheumatoid arthritis (RA) D) Gout

ANS: B Rationale: SLE has a high degree of neuro involvement and can result in central nervous system changes. The client and family members are asked about any behavioral changes, including manifestations of neurosis or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central nervous system manifestations. OA, RA, and gout lack this dimension.

A client with rheumatoid arthritis comes to the clinic reporting pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize? A. Take OTC calcium supplements consistently. B. Restrict consumption of foods high in purines. C. Ensure fluid intake of at least 4 L per day. D. Restrict weight-bearing on right foot

ANS: B Rationale: Although severe dietary restriction is not necessary, the nurse should encourage the pt. to restrict consumption of foods high in purines, especially organ meats. Calcium supplementation is not necessary & activity should be maintained as tolerated. Increased fluid intake is beneficial, but it is not necessary for the client to consume more than 4 L daily

A nurse is caring for a client who is suspected of having giant cell arteritis (GCA). Which laboratory tests are most useful in diagnosing this rheumatic disorder? Select all that apply. A. Erythrocyte count B. Erythrocyte sedimentation rate C. Creatinine clearance D. C-reactive protein E. D-dimer

ANS: B, D Rationale: Simultaneous elevation in the erythrocyte sedimentation rate and C-reactive protein has a sensitivity of 98.6% and a specificity of 75.7% in making the diagnosis of GCA when coupled with clinical findings. Erythrocyte counts, creatinine clearance, and D-dimer are not diagnostically useful

A nurse is educating a client with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make? A. Ensuring adequate rest B. Limiting exposure to sunlight C. Limiting intake of alcohol D. Smoking cessation

ANS: C Rationale: Alcohol and red meat can precipitate an acute exacerbation of gout. Each of the other listed actions is consistent with good health, but none directly addresses the factors that exacerbate gout.

A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement? A. "I'll make sure I get enough exposure to sunlight to keep up my vitamin D levels." B. "I'll try to be as physically active as possible between flare-ups." C. "I'll make sure to monitor my body temperature on a regular basis." D. "I'll stop taking my steroids when I get relief from my symptoms."

ANS: C Rationale: FEVER can signal an exacerbation & should be reported to the health care provider. Sunlight and other sources of ultraviolet light may precipitate SEVERE SKIN REACTIONS and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and PLAN REST PERIODS Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. As well, these drugs should not be independently adjusted by the client.

A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A. Cool joints with decreased range of motion B. Signs of systemic infection C. Joint stiffness lasting longer than 1 hour, especially in the morning D. Visible atrophy of the knee and shoulder joints

ANS: C Rationale: In addition to joint pain and swelling, another classic sign of RA is joint stiffness lasting longer than 1 hour, especially in the morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the disease. Joints are often warm rather than cool.

A patient with SLE asks the nurse why she has to come to the office so often for check-ups. What would be the nurses best response? A) Taking care of you in the best way involves seeing you face to face. B) Taking care of you in the best way involves making sure you are taking your medication the way it is ordered. C) Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working. D) Taking care of you in the best way involves drawing blood work every month.

ANS: C Rationale: The goals of treatment include preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease-related disabilities, and preventing complications from therapy. Management of SLE involves regular monitoring to assess disease process and therapeutic effectiveness.

A nurse is creating a teaching plan for a client who has a recent diagnosis of scleroderma. Which topics should the nurse address during health education? Select all that apply. A. Surgical treatment options B. Weight loss C. Management of Raynaud-type symptoms D. Exercise E. Skin care

ANS: C, D, E Rationale: Pt. teaching for the client with scleroderma focuses on management of Raynaud phenomenon, moderate exercise to prevent joint contractures, and meticulous skin care. Surgical treatment options do not exist, and weight loss is not a central concern.

A client with rheumatic disease has developed a gastrointestinal (GI) bleed. The nurse caring for the client should further assess for medications that typically exacerbate this condition. Which medication applies? A. Corticosteroids B. Immunomodulators C. Antimalarials D. Salicylate therapy

ANS: D Rationale: GI bleeding is an adverse effect that is associated with salicylates. (LIKE ASPIRIN!!***) Corticosteroids, antimalarials, and immunomodulators do not normally have this adverse effect.

A nurse is providing care for a client who has a recent diagnosis of giant cell arteritis (GCA). Which aspect of physical assessment should the nurse prioritize? A. Subtle signs of bleeding disorders B. The metatarsal joints and phalangeal joints C. Thoracic pain that is exacerbated by activity D. Headaches and jaw pain

ANS: D Rationale: Assessment of the client with GCA focuses on musculoskeletal tenderness, weakness, and decreased function. Careful attention should be directed toward assessing the head (for changes in vision, headaches, and jaw claudication). There is not a particular clinical focus on the potential for bleeding, hand and foot pain, or thoracic pain

A 40-year-old woman was diagnosed with Raynaud phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The client also states that many of her skin surfaces are "stiff, like the skin is being stretched from all directions." The nurse should recognize the need for medical referral for the assessment of what health problem? A. Giant cell arteritis (GCA) B. Fibromyalgia (FM) C. Rheumatoid arthritis (RA) D. Scleroderma

ANS: D Rationale: Scleroderma starts insidiously with Raynaud phenomenon and swelling in the hands. Later, the skin and the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. This progression of symptoms is inconsistent with GCA, FM, or RA

A client is diagnosed with giant cell arteritis (GCA) and is placed on corticosteroids. A concern for this client is that the client will stop taking the medication as soon as the client starts to feel better. The nurse must emphasize the need for continued adherence to the prescribed medication so that the client can avoid which complication? A. Venous thromboembolism B. Osteoporosis C. Degenerative joint disease D. Blindness

ANS: D Rationale: The nurse must emphasize to the client the need for continued adherence to the prescribed medication regimen to avoid complications of giant cell arteritis, such as blindness. Venous thromboembolism, osteoporosis, and degenerative joint disease are not among the most common complications for GCA.

Allopurinol has been prescribed for a client receiving treatment for gout. The nurse caring for this client knows to assess the client for bone marrow suppression, which may be manifested by what diagnostic finding? A. Hyperuricemia B. Increased erythrocyte sedimentation rate C. Elevated serum creatinine D. Decreased platelets

ANS: DRationale: Thrombocytopenia occurs in bone marrow suppression. Hyperuricemia occurs in gout, but is not caused by bone marrow suppression. Increased erythrocyte sedimentation rate may occur from inflammation associated with gout, but is not related to bone marrow suppression. An elevated serum creatinine level may indicate renal damage, but this is not associated with the use of allopurinol.

A progressive inflammatory disease that presents with pain and stiffness of the spine leading to bony ankylosis is?

Ankylosing Spondylitis

. A 19-year-old patient who is taking azathioprine (Imuran) for systemic lupus erythematosus has a check-up before leaving home for college. The health care provider writes all of these orders. Which one should the nurse question? A. Naproxen (Aleve) 200 mg BID B. Give measles-mumps-rubella (MMR) immunization C. Draw anti-DNA titer D. Famotidine (Pepcid) 20 mg daily

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

Identify which patient below is at MOST risk for developing gout: A.) A 56 year old male who reports consuming foods low in purines B.) A 45 year old male a BMI of 40 reports taking hydrochlorothiazide and aspirin C.) A 39 year old female hospitalized with bulimia that has a BMI of 24 D.) A 27 year ol female with ulcerative colitis

B A 45 year old male a BMI of 40 reports taking hydrochlorothiazide and aspirin

A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the patient appears to have lost some of her ability to function since her last office visit. Which of the following is the most appropriate action? A) Arrange a family meeting in order to explore assisted living options. B) Refer the patient to a support group. C) Arrange for the patient to be assessed in her home environment. D) Refer the patient to social work.

C Rationale: Assessment in the client's home setting can often reveal more meaningful data than an assessment in the health care setting. There is no indication that assisted living is a pressing need or that the client would benefit from social work or a support group.

A clinic nurse is caring for a client newly diagnosed with fibromyalgia. When developing a care plan for this client, which nursing diagnosis should the nurse prioritize? A. Impaired urinary elimination related to neuropathy B. Altered nutrition related to impaired absorption C. Disturbed sleep pattern related to central nervous system stimulation D. Fatigue related to pain

D Rationale: Fibromyalgia is characterized by fatigue, generalized muscle aching, and stiffness. Impaired urinary elimination is not a common manifestation of the disease. Altered nutrition and disturbed sleep pattern are potential nursing diagnoses, but are not the priority.

A nurses plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals? A) Maximize range of motion while minimizing exertion B) Increase joint size and strength C) Limit energy output in order to preserve strength for healing D) Preserve and increase range of motion while limiting joint stress

D) Preserve and increase range of motion while limiting joint stress

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

Facial erythema, pericarditis, pleuritis, fever, and weight loss

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

may feel as if their symptoms are not taken seriously.