#1 Chapter 38: Assessment and Management of Patients With Rheumatic Disorders

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. Which of the following would the nurse expect to find? a) Elevated erythrocyte sedimentation rate b) Increased albumin levels c) Increased red blood cell count d) Increased C4 complement

a) Elevated erythrocyte sedimentation rate Explanation: The erythrocyte sedimentation rate (ESR) may be elevated, particularly as the disease progresses. ESR shows inflammation associated with RA. Red blood cell count and C4 complement component are decreased. Serum protein electrophoresis may disclose increased levels of gamma and alpha globulin but decreased albumin. pg.1058

A client with rheumatoid arthritis is prescribed a tumor necrosis factor (TNF)-alpha inhibitor. Which of the following might be prescribed? a) Etanercept b) Celecoxib c) Diclofenac d) Indomethacin

a) Etanercept Explanation: Etanercept is an example of a tumor necrosis factor (TNF)-alpha inhibitor used to treat rheumatoid arthritis. Diclofenac and indomethacin are nonsteroidal anti-inflammatory drugs (NSAIDs). Celecoxib is a cyclooxygenase-2 (COX-2) inhibitor. pg.1061

A patient is being placed on a purine-restricted diet. What food shouldbe suggested by the nurse? a. Dairy products b. Organ meats c. Raw vegetables d. Shellfish

a. Dairy products

Which of the following refers to fixation of a joint? a) Synovitis b) Ankylosis c) Pannus d) Articulations

b) Ankylosis Explanation: Fixation of a joint, called ankylosis, eliminates friction, but at the drastic cost of immobility. Inflammation is manifested in the joints as synovitis. Pannus has a destructive effect on the adjacent cartilage and bone. Articulations are joints. pg.1078

A patient has a serum study that is positive for the rheumatoid factor. What does the nurse understand is the significance of this test result? a) Specific for RA b) Diagnostic for Sjögren's syndrome c) Diagnostic for SLE d) Suggestive of RA

d) Suggestive of RA Explanation: Rheumatoid factor is present in about 80% of patients with RA, but its presence alone is not diagnostic of RA, and its absence does not rule out the diagnosis. pg.1066

The nurse is gathering objective data for a client at the clinic complaining of arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. What does the nurse recognize this deformity as? a) Ulnar deviation b) Boutonnière deformity c) Rheumatoid nodules d) Swan neck deformity

d) Swan neck deformity Explanation: A swan neck deformity is a hyperextension of the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. A Boutonnière deformity is a persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint. Ulnar deviation is when the fingers are deviating laterally toward the ulna. A rheumatoid nodule is a subcutaneous nodule. pg.1066

a systemic autoimmune disease with symmetric arthritic manifestations and multiple extra-articular features

rheumatoid arthritis

The nurse is educating the patient with gout about ways to preventreoccurrence of an attack. What foods should the nurse encourage thepatient to avoid? a. Baked chicken b. Steak c. Asparagus d. Pineapple

steak - Both alcohol and consumption of a large meal, especially with red meat, can lead to increases in free fatty acid concentrations; they also are implicated as triggers to acute gout attacks

In RA, the autoimmune reaction primarily occurs in the ________.

synovial tissue

The ongoing nature of most rheumatic diseases makes it important to maintain and, when possible, improve joint mobility and overall functional status.

true

A patient is prescribed a DMARD that is successful in the treatment of RA but has side effects, including retinal eye changes. What medication does the nurse anticipate educating the patient about? a) Azathioprine (Imuran) b) Hydroxychloroquine (Plaquenil) c) Aurothioglucose (Solganal) d) Diclofenac (Voltaren)

b) Hydroxychloroquine (Plaquenil) Explanation: The DMARD hydroxychloroquine (Plaquenil) is associated with visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. The nurse should emphasize the need for ophthalmologic examinations (every 6-12 months). pg.1060

A patient is hospitalized with a severe case of gout. The patient hasgross swelling of the large toe and rates pain a 10 out of 10. With adiagnosis of gout, what should the laboratory results reveal? a. Glucosuria b. Hyperuricemia c. Hyperproteinuria d. Ketonuria

b. Hyperuricemia occurs when there's too much uric acid in your blood. High uric acid levels can lead to several diseases, including a painful type of arthritis called gout.

A patient is prescribed a DMARD that is successful in the treatmentof rheumatoid arthritis (RA) but has side effects, including retinal eyechanges. What medication does the nurse anticipate educating thepatient about? a. Azathioprine b. Diclofenac c. Hydroxychloroquine d. Aurothioglucose

c. Hydroxychloroquine - Administer concurrently with NSAIDs. - Assess for visual changes, GI upset, skin rash, headaches, photosensitivity, bleaching of hair. - Emphasize need for ophthalmologic examinations (every 6-12 months).

COX-2 enzyme blockers are less likely to cause gastric irritation and ulceration than other NSAIDs; however, they are associated with increased risk of __________ disease and must be used with caution

cardiovascular

Fibromyalgia

chronic pain syndrome that involves chronic fatigue, generalized muscle aching, stiffness, sleep disturbances, and functional impairment. I

The client asks the nurse about types of exercise that do not stress the joints. Which of the following would be an inappropriate type of exercise for the nurse to include in the teaching plan? a) T'ai chi b) Yoga c) Pilates d) Jogging

d) Jogging Explanation: Jogging would be an inappropriate type of exercise, as it is a high impact, jarring type of exercise. pg.1077

A client with rheumatoid arthritis has experienced increasing pain and progressing inflammation of the hands and feet. What would be the expected goal of the likely prescribed treatment regimen? a) Eradicating pain b) Promoting sleep c) Eliminating deformities d) Minimizing damage

d) Minimizing damage Explanation: Although RA cannot be cured, much can be done to minimize damage. Treatment goals include decreasing joint inflammation before bony ankylosis occurs, relieving discomfort, preventing or correcting deformities, and maintaining or restoring function of affected structures. Early treatment leads to the best results. pg.1066

The nurse knows that a patient who presents with the symptom of "blanching of fingers on exposure to cold" would be assessed for what rheumatic disease? a) Reiter's syndrome b) Ankylosing spondylitis c) Sjögren's syndrome d) Raynaud's phenomenon

d) Raynaud's phenomenon Explanation: Blanching of fingers on exposure to cold is associated with Raynaud's phenomenon. pg.1057

A patient has a serum study that is positive for the rheumatoid factor.What does the nurse understand is the significance of this test result? a. The test results are diagnostic for Sjögren syndrome b. The test results are diagnostic for systemic lupus erythematosus c. The test results are specific for rheumatoid arthritis d. The test results are suggestive of rheumatoid arthritis

d. The test results are suggestive of rheumatoid arthritis

The nurse should be aware that no NSAIDs, not even the COX-2 inhibitors, prevent erosions or alter disease progression and, consequently, are medications useful only for symptom relief.

true

when does the immunologic inflammatory process begins?

when antigens are presented to T lymphocytes, leading to a proliferation of T and B cells.

A patient's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary care provider has added prednisone to the patient's drug regimen. What principle will guide this aspect of the patient's treatment? A) The patient will need daily blood testing for the duration of treatment. B) The patient must stop all other drugs 72 hours before starting prednisone. C) The drug should be used at the highest dose the patient can tolerate. D) The drug should be used for as short a time as possible.

D Corticosteroids are used for shortest duration and at lowest dose possible to minimize adverse effects.

______________disease refers to a group of systemic disorders that are chronic in nature and are characterized by diffuse inflammation and degeneration in the connective tissues.

Diffuse connective tissue

What is the difference between the pathophysiology of inflammatoryrheumatic disease and that of degenerative rheumatic disease?

In inflammatory rheumatic disease, the inflammation occurs as the result of an immune response. Newly formed synovial tissue is infiltrated with inflammatory cells (pannus formation), and joint degeneration occurs as a secondary process. In degenerative rheumatic disease, synovitis results from mechanical irritation. A secondary inflammation occurs.

The cardiac system is also commonly affected in SLE. _____________ is the most common cardiac manifestation.Patients may present with substernal chest pain that is aggravated by movement or inspiration.

Pericarditis

Polymyositis first symptoms

Proximal muscle weakness is typically the first symptom. Muscle weakness is usually symmetric and diffuse.

Heberden's and Bouchard's nodes

RA

A patient is receiving gold sodium thiomalate for the treatment ofrheumatoid arthritis (RA). What does the nurse understand about theaction of this compound?

The drug inhibits T- and B-cell activity

osteophyte

a bony outgrowth or protuberance; bone spur

The nurse is caring for a client with rheumatoid arthritis who suffers with chronic pain in the hands. When would be the best time for the nurse to perform range-of-motion exercises? a) After the client has had a warm paraffin hand bath b) First thing in the morning when the client wakes c) After the client has a diagnostic test d) After cool compresses have been applied to the hands

a) After the client has had a warm paraffin hand bath Explanation: Whether resting or moving, clients in this stage of the disease have considerable chronic pain, which typically is worse in the morning after a night's rest. Warmth helps decrease the symptoms of pain and will be the best time to perform range of motion exercises. pg.1056

ankylosis

fixation or immobility of a joint

Capsaicin (Zostrix)

for rheumatic diseases made from hot pepper - Instruct patient to apply sparingly - avoid areas of open skin - avoid contact with eyes and mucous membranes. - Wash hands carefully after application. - Assess for local skin irritation.

scleroderma

hardening of the skin

A large group of genes, called _____________ genes, has been linked to the immune response and the development of multiple rheumatologic diseases

human leukocyte antigen (HLA)

Erythrocyte count

Erythrocyte count

degenerative rheumatic diseases

inflammation also occurs, but as a secondary process.

Polymyositis

inflammation of many muscles

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Ibuprofen (Motrin) Meloxicam (Mobic) Celecoxib (Celebrex)

Sjögren's syndrome

It is one of the most common autoimmune disorders

Creatinine

Metabolic waste excreted through the kidneys

Patients with RA CBC results

Patients may exhibit anemia, and platelets may be elevated due to the inflammatory process

Deformities of the hands (e.g., ulnar deviation and swan neck deformity) and feet are common in

RA

Cigarette smoking is one modifiable risk factor that has been shown to be highly related to __________

Rheumatoid Arthritis

CREST syndrome

Scleroderma

classic symptoms of RA

Symmetric joint pain swelling warmth erythema lack of function

In the inflammatory process in rheumatic diseases, a triggering eventstarts the process by activating ________

T lymphocytes

Purine rich foods

Whole grain breads and cereals, oatmeal, wheat germ, wheat bran, meat gravies, fresh and saltwater fish, beans, organ meats, mushrooms, green peas, spinach, asparagus, cauliflower, and baker's and brewer's yeast are all high in purine. Lentils, which are beans, are a rich source of purines.

What are the clinical manifestations of degenerative joint disease(osteoarthritis [OA])?

joint pain, stiffness, and functional impairmen

A patient is seen in the office for reports of joint pain, swelling, and alow-grade fever. What blood studies does the nurse know areconsistent with a positive diagnosis of RA? (Select all that apply.) a. Positive C-reactive protein (CRP) b. Positive antinuclear antibody (ANA) c. Red blood cell (RBC) count of <4.0 million/mcL d. Serum complement level (C3) of >130 mg/dL e. Aspartate aminotransferase (AST) and alanine transaminase(ALT) levels of 7 units/L

a. Positive C-reactive protein (CRP) b. Positive antinuclear antibody (ANA) d. Serum complement level (C3) of >130 mg/dL

increase creatinine

may indicate kidney damage in SLE, scleroderma, and polyarteritis

Synovial fluid from an inflamed joint is characteristically ________,________, and ________

milky, cloudy, dark yellow

most common symptom in the rheumatic diseases is ______

pain.

tophi

accumulation of crystalline deposits in articular surfaces, bones, soft tissue, and cartilage

inflammation of a joint

arthritis

Women who have SLE are also at risk for early-onset _____________, making them much more likely to suffer myocardial infarction or stroke.

atherosclerosis

A hallmark of rheumatologic diseases is ____________, where the body mistakenly recognizes its own tissue as a foreign antigen. It leads to destruction of tissue via the inflammatory process, along with chronic and long-standing pain.

autoimmunity

There are more than 100 types of rheumatic diseases.

true

subchondral bone

bony plate that supports the articular cartilage

The rheumatoid arthritis (RA) reaction produces enzymes that breakdown ________.

collagen

pathophysiologic features rheumatologic diseases

- inflammation -autoimmunity -degeneration

The American College of Rheumatology and the European League Against Rheumatism have collaborated and established new criteria for classifying RA. These criteria are based on a point system where a total score of ___ or greater is required for the diagnosis of RA.

6

A patient comes to the clinic with an inflamed wrist. How should thenurse splint the joint to immobilize it? a. Slight dorsiflexion b. Extension c. Hyperextension d. Internal rotation

d) Slight dorsiflexion Devices such as braces, splints, and assistive devices for ambulation (e.g., canes, crutches, walkers) ease pain by limiting movement or stress from putting weight on painful joints. Acutely inflamed joints can be rested by applying splints to limit motion. Splints also support the joint to relieve spasm.

Psoriatic arthritis

An inflammatory arthritis associated with psoriasis of the skin

disease-modifying antirheumatic drugs (DMARDs) function

As their name suggests, DMARDs have the ability to suppress the autoimmune response; alter disease progression; and stop or decrease further tissue damage on the joints, cartilage, and organs

A patient with rheumatic disease is complaining of stomatitis. The nurse caring for the patient should further assess the patient for the adverse effects of what medications? A) Corticosteroids B) Gold-containing compounds C) Antimalarials D) Salicylate therapy

B Stomatitis is an adverse effect that is associated with gold therapy. Steroids, antimalarials, and salicylates do not normally have this adverse effect.

Creatinine normal range

0.7-1.4 mg/dL (62-124 mcmol/L)

A patient has been admitted to a medical unit with a diagnosis of polymyalgia rheumatica (PMR). The nurse should be aware of what aspects of PMR? Select all that apply. A) PMR has an association with the genetic marker HLA-DR4. B) Immunoglobulin deposits occur in PMR. C) PMR is considered to be a "wear-and-tear" disease. D) Foods high in purines exacerbate the biochemical processes that occur in PMR. E) PMR occurs predominately in Caucasians.

A,B,E (The underlying mechanism involved with polymyalgia rheumatica is unknown. This disease occurs predominately in Caucasians and often in first-degree relatives. An association with the genetic marker HLA-DR4 suggests a familial predisposition. Immunoglobulin deposits in the walls of inflamed temporal arteries also suggest an autoimmune process. Purines are unrelated and it is not a result of physical degeneration.)

Scleroderma starts insidiously with Raynaud's phenomenon and swelling in the hands. Raynaud's phenomenon is observed in _______% of patients with scleroderma and can precede the official scleroderma diagnosis for years

90

It has been estimated that the primary cause of death for up to 40% of patients diagnosed with RA is cardiovascular disease. The cause of cardiovascular disease in these patients is thought to be due to:

- elevated lipid values, chronic inflammation - dysfunction of the endothelium - abnormal homocysteine levels

rheumatic diseases

-encompass autoimmune, degenerative, inflammatory, and systemic conditions that affect the joints, muscles, and soft tissues of the body. - most commonly manifest the clinical features of arthritis -

A nurse is planning the care of a patient who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. What nursing diagnosis is most likely to apply to this woman's care needs? A) Ineffective Role Performance Related to Pain B) Risk for Impaired Skin Integrity Related to Myalgia C) Risk for Infection Related to Tissue Alterations D) Unilateral Neglect Related to Neuropathic Pain

A (Typically, patients with fibromyalgia have endured their symptoms for a long period of time. The neuropathic pain accompanying FM can often impair a patient's ability to perform normal roles and functions. Skin integrity is unaffected and the disease has no associated infection risk. Activity limitations may result in neglect, but not of a unilateral nature.)

A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed cyclophosphamide (Cytoxan). The nurse's subsequent assessments should address what potential adverse effect? A) Infection B) Acute confusion C) Sedation D) Malignant hyperthermia

A (Feedback: When administering immunosuppressives such as Cytoxan, 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 nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? A) Petechiae B) Butterfly rash C) Jaundice D) Skin sloughing

B (An acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks occurs in SLE. Petechiae are pinpoint skin hemorrhages, which are not a clinical manifestation of SLE. Patients with SLE do not typically experience jaundice or skin sloughing.)

A patient with polymyositisis experiencing challenges with activities of daily living as a result of proximal muscle weakness. What is the most appropriate nursing action? A) Initiate a program of passive range of motion exercises B) Facilitate referrals to occupational and physical therapy C) Administer skeletal muscle relaxants as ordered D) Encourage a progressive program of weight-bearing exercise

B -Patients with polymyositis may have symptoms similar to those of other inflammatory diseases. However, proximal muscle weakness is characteristic, making activities such as hair combing, reaching overhead, and using stairs difficult. - Therefore, use of assistive devices may be recommended, and referral to occupational or physical therapy may be warranted.

A patient with SLE has come to the clinic for a routine check-up. When auscultating the patient's apical heart rate, the nurse notes the presence of a distinct "scratching" sound. What is the nurse's most appropriate action? A) Reposition the patient and auscultate posteriorly. B) Document the presence of S3 and monitor the patient closely. C) Inform the primary care provider that a friction rub may be present. D) Inform the primary care provider that the patient may have pneumonia.

C Patients with SLE are susceptible to developing a pericardial friction rub, possibly associated with myocarditis and accompanying pleural effusions; this warrants prompt medical follow-up.

A clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient? A) Impaired Urinary Elimination Related to Neuropathy B) Altered Nutrition Related to Impaired Absorption C) Disturbed Sleep Pattern Related to CNS Stimulation D) Fatigue Related to Pain

D (Feedback: 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.)

symptoms rheumatic diseases

PAIN, joint swelling, limited movement, stiffness, weakness, and FATIGUE.

RA is a systemic disease with multiple extra-articular features. Most common are fever, weight loss, fatigue, anemia, lymph node enlargement, and ____________ phenomenon (cold- and stress-induced vasospasm causing episodes of digital blanching or cyanosis).

Raynaud's

in this disease the skin and subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. Wrinkles and lines are obliterated. The skin is dry because sweat secretion over the involved region is suppressed. The extremities stiffen and lose mobility

Scleroderma

Deformities of RA differ from those seen with osteoarthritis (OA), such as Heberden's and Bouchard's nodes.

TRUE

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process? a) "It will get better and worse again." b) "It will never get any better than it is right now." c) "When it clears up, it will never come back." d) "I'll definitely need surgery for this."

a) "It will get better and worse again." Explanation: The client demonstrates understanding of rheumatoid arthritis if he expresses that it's an unpredictable disease characterized by periods of exacerbation and remission. There's no cure for rheumatoid arthritis, but symptoms can be managed. Surgery may be indicated in some cases. pg.1062

Which client is most likely to develop systemic lupus erythematosus (SLE)? a) A 27-year-old black female b) A 25-year-old white male c) A 35-year-old Hispanic male d) A 25-year-old Jewish female

a) A 27-year-old black female Explanation: SLE strikes nearly 10 times as many women as men and is most common in women between ages 15 and 40. SLE affects more black women than white women; its incidence is about 1 in every 250 black women, compared to 1 in every 700 white women. pg.1069

A patient is seen in the office for complaints of joint pain, swelling, and a low-grade fever. What blood studies does the nurse know are consistent with a positive diagnosis of RA? (Select all that apply.) a) Positive antinuclear antibody (ANA) b) Positive C-reactive protein (CRP) c) Aspartate aminotransferase (AST) and alanine transaminase (ALT) levels of 7 units/L d) Red blood cell (RBC) count of <4.0 million/mcL e) Red blood cell (RBC) count of >4.0 million/mcL

a) Positive antinuclear antibody (ANA) b) Positive C-reactive protein (CRP) d) Red blood cell (RBC) count of <4.0 million/mcL Explanation: Several assessment findings are associated with RA: rheumatoid nodules, joint inflammation detected on palpation, and laboratory findings. The history and physical examination focuses on manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tend to be significantly elevated in the acute phases of RA and are therefore useful in monitoring active disease and disease progression. The red blood cell count and C4 complement component are decreased. Antinuclear antibody (ANA) test results may also be positive. pg.1066

Which of the following clinical manifestations would the nurse expect to find in a client who has had rheumatoid arthritis for several years? a) Small joint involvement b) Asymmetric joint involvement c) Bouchard's nodes d) Obesity

a) Small joint involvement Explanation: Clinical manifestations of rheumatoid arthritis are usually bilateral and symmetrical and include small joint involvement and joint stiffness in the morning. Other systemic manifestations occur. pg.1065

The nurse is teaching the client newly diagnosed with systemic lupus erythematous about the condition. Which statement by the client indicates teaching was effective? a) "I do not need to make any changes in my diet." b) "I should avoid prolonged sun exposure." c) "My energy level will gradually increase over time." d) "My medications will ultimately correct my problem."

b) "I should avoid prolonged sun exposure." Explanation: Prolonged exposure to sun and ultraviolet light can cause exacerbations and disease progression. pg.1072

The client with rheumatoid arthritis has a red blood cell count of 3.2 cells/cu mm. Which nursing diagnosis has the highest priority for the client? a) Self-care deficit: Bathing b) Ineffective airway clearance c) Fatigue d) Risk for infection

c) Fatigue Explanation: Low red blood cell count can be related to inadequate nutrition. Insufficient RBC levels compromise the oxygen-carrying capacity of the blood, which can lead to fatigue. pg.1063

Which of the following points should be included in the medication-teaching plan for a patient taking adalimumab (Humira)? a) The medication is administered IM. b) The medication is given at room temperature. c) It is important to monitor for injection site reactions. d) The patient should continue taking the medication if fever occurs.

c) It is important to monitor for injection site reactions. Explanation: It is important to monitor for injection site reactions. The medication is injected subcutaneously and must be refrigerated. The medication should be withheld if fever occurs. pg.1061

Which of the following procedures involves a surgical fusion of the joint? a) Synovectomy b) Tenorrhaphy c) Osteotomy d) Arthrodesis

d) Arthrodesis Explanation: An arthrodesis is a surgical fusion of the joint. Synovectomy is the excision of the synovial membrane. Tenorrhaphy is the suturing of a tendon. An osteotomy alters the distribution of the weight within the joint. pg.1067

A patient with an acute exacerbation of arthritis is temporarily confined to bed. What position can the nurse recommend to prevent flexion deformities? a) Supine with pillows under the knees b) Semi-Fowler's c) Side-lying with pillows supporting the shoulders and legs d) Prone

d) Prone Explanation: It is best for the patient with rheumatoid arthritis to lie prone several times daily to prevent hip flexion contracture.

autoimmunity

reaction of immune response to one's own tissues

arthroplasty

replacement of a joint

What type of clinical manifestations does a patient with polymyalgia rheumatic (PMR) present with?

severe proximal muscle discomfort with mild joint swelling. Severe aching in the neck, shoulder, and pelvic muscles is common. Stiffness, noticeable most often in the morning and after periods of inactivity, can become so severe that patients struggle putting on a coat or combing their hair.

pannus

proliferation of newly formed synovial tissue infiltrated with inflammatory cells

Several assessment findings are associated with RA:

-rheumatoid nodules - joint inflammation detected on palpation -bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints.

A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this patient, 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 liters per day. D) Restrict weight-bearing on right foot.

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

A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following? A) Hydromorphone (Dilaudid) B) Methotrexate (Rheumatrex) C) Allopurinol (Zyloprim) D) Prednisone

B In the past, a step-wise approach starting with NSAIDs was standard of care. However, evidence clearly documenting the benefits of early DMARD (methotrexate [Rheumatrex], antimalarials, leflunomide [Arava], or sulfasalazine [Azulfidine]) treatment has changed national guidelines for management. Now it is recommended that treatment with the non-biologic DMARDs begin within 3 months of disease onset.

A nurse is caring for a patient who is suspected of having giant cell arteritis (GCA). What 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

B,D (Feedback: Simultaneous elevation in the ESR and CRP have a sensitivity of 88% and a specificity of 98% in making the diagnosis of GCA when coupled with clinical findings. Erythrocyte counts, creatinine clearance, and D-dimer are not diagnostically useful.)

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 Assessment in the patient's home setting can often reveal more meaningful data than an assessment in the health care setting.

__________ syndrome is a systemic autoimmune disease that progressively affects the lacrimal and salivary glands of the body. More than 90% of patients affected are women, and the onset tends to begin between 35 and 50 years of age

Sjögren's

Of the following, which drug is not used in the treatment of rheumatoid arthritis? a) Allopurinol (Zyloprim) b) Adalimumab (Humira) c) Methotrexate (Rheumatrex) d) Etanercept (Enbrel

a) Allopurinol (Zyloprim) Explanation: Allopurinol (Zyloprim) is used in the treatment of gout. Etanercept (Enbrel), adalimumab (Humira), and methotrexate (Rheumatrex) are all used in the treatment of rheumatoid arthritis. pg.1079

COX-2 medications block the enzyme involved in inflammation (COX-2) while leaving intact the enzyme involved in protecting the stomach lining (COX-1).

true

DMARDs have been found to halt the progression of bone loss and destruction and can induce remission

true

In general, women are two to nine times more commonly affected by rheumatologic diseases than men

true

Patients with RA frequently experience anorexia, weight loss, and anemia.

true

Rheumatoid factor is present in about 70% to 80% of patients with RA, but its presence alone is not diagnostic of RA, and its absence does not rule out the diagnosis.

true

Liver and kidney monitoring is recommended for most ___________ therapy because it can cause elevation of the liver enzymes and can also affect kidney function.

DMARD

CREST stands for

- calcinosis (calcium deposits in the tissues) - Raynaud's phenomenon - esophageal hardening and dysfunction -sclerodactyly (scleroderma of the digits) -telangiectasia (capillary dilation that forms a vascular lesion)

Pathophysiology and associated physical signs of rheumatoid arthritis.

1st. -presentation of antigen to T cell 2nd. -T and B cell proliferation -angiogenesis in synovial lining 3rd. -neutrophil accumulation in synovial fluid -cell proliferation - no cartilage invasion 4th. synovitis -ealsy pannus invasion of cartilage - condrocyte proliferation - laxity of ligament

A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient expresses angerand irritation when her call bell isn't answered immediately. What would be the most appropriate response? A) "You seem like you're feeling angry. Is that something that we could talk about?" B) "Try to remember that stress can make your symptoms worse." C) "Would you like to talk about the problem with the nursing supervisor?" D) "I can see you're angry. I'll come back when you've calmed down."

A (The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care, as well as sensitivity to the psychological reactions of the patient. Offering to listen to the patient express anger can help the nurse and the patient understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the patient to calm down doesn't acknowledge her feelings. Ignoring the patient's feelings suggests that the nurse has no interest in what the patient has said. Offering to get the nursing supervisor also does not acknowledge the patient's feelings.)

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

A (Feedback: 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 patient is undergoing diagnostic testing to determine the etiology of recent joint pain. The patient asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A) "OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B) "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." C) "OA originates with an infection. RA is a result of your body's cells attacking one another." D) "OA is associated with impaired immune function; RA is a consequence of physical damage."

A - OA is a degenerative arthritis with a noninflammatory etiology, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints, with spur development. - RA is characterized by inflammation of synovial membranes and surrounding structures.

A patient who has been newly diagnosed with systemic lupus erythematosus (SLE) has been admitted to the medical unit. Which of the following nursing diagnoses is the most plausible inclusion in the plan of care? A) Fatigue Related to Anemia B) Risk for Ineffective Tissue Perfusion Related to Venous Thromboembolism C) Acute Confusion Related to Increased Serum Ammonia Levels D) Risk for Ineffective Tissue Perfusion Related to Increased Hematocrit

A Patients with SLE nearly always experience fatigue, which is partly attributable to anemia. Ammonia levels are not affected and hematocrit is typically low, not high. VTE is not one of the central complications of SLE.)

The nurse is preparing to care for a patient who has scleroderma. The nurse refers to resources that describe CREST syndrome. Which of the following is a component of CREST syndrome? A) Raynaud's phenomenon B) Thyroid dysfunction C) Esophageal varices D) Osteopenia

A The "R" in CREST stands for Raynaud's phenomenon.

A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the patient 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."

A - Tinnitus is associated with salicylate therapy.

A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patient's care, what goal should the nurse include? A) The patient will express satisfaction with her ability to perform ADLs. B) The patient will recover from OA within 6 months. C) The patient will adhere to the prescribed plan of care. D) The patient will deny signs or symptoms of OA.

A Feedback: Pain management and optimal functional ability are major goals of nursing interventions for OA. Cure is not a possibility and it is unrealistic to expect a complete absence of signs and symptoms. Adherence to the plan of care is highly beneficial, but this is not the priority goal of care.

A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor? A) The patient has a 30 pack-year smoking history. B) The patient's body mass index is 34 (obese). C) The patient has primary hypertension. D) The patient is 58 years old.

B (Feedback: Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not include smoking or hypertension. Incidence increases with age, but a patient who is 58 would not yet face a significantly heightened risk.)

A 21-year-old male has just been diagnosed with a spondyloarthropathy. What will be a priority nursing intervention for this patient? A) Referral for assistive devices B) Teaching about symptom management C) Referral to classes to stop smoking D) Setting up an exercise program

B Major nursing interventions in the spondyloarthropathies are related to symptom management and maintenance of optimal functioning. This is a priority over the use of assistive devices, smoking cessation, and exercise programs, though these topics may be of importance for some patients.

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

B SLE has a high degree of neurologic involvement, and can result in central nervous system changes. The patient 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.

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

B - Antimalarials may cause visual changes; regular ophthalmologic examinations are necessary. - Tinnitus is associated with salicylate therapy - stomatitis is associated with gold therapy - hirsutism is associated with corticosteroid therapy.

A patient has just been told by his physician that he has scleroderma. The physician tells the patient that he is going to order some tests to assess for systemic involvement. The nurse knows that priority systems to be assessed include what? A) Hepatic B) Gastrointestinal C) Genitourinary D) Neurologic

B Assessment of systemic involvement with scleroderma requires a systems review with special attention to gastrointestinal, pulmonary, renal, and cardiac systems.

A nurse is performing the health history and physical assessment of a patient 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, especially in the morning D) Visible atrophy of the knee and shoulder joints

C (In addition to joint pain and swelling, another classic sign of RA is joint stiffness, 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 nurse's 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."

C (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 activity and therapeutic effectiveness. Stating the benefit of face-to-face interaction does not answer the patient's question. Blood work is not necessarily drawn monthly and assessing medication adherence is not the sole purpose of visits.)

A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse should describe which of the following? A) Autoimmune processes in the joints B) Chronic metabolic acidosis C) Increased uric acid levels D) Unstable serum calcium levels

C (Feedback: Gout is caused by hyperuricemia (increased serum uric acid). Gout is not categorized as an autoimmune disease and it does not result from metabolic acidosis or unstable serum calcium levels.)

A clinic nurse is caring for a patient diagnosed with rheumatoid arthritis (RA). The patient tells the nurse that she has not been taking her medication because she usually cannot remove the childproof medication lids. How can the nurse best facilitate the patient's adherence to her medication regimen? A) Encourage the patient to store the bottles with their tops removed. B) Have a trusted family member take over the management of the patient's medication regimen. C) Encourage her to have her pharmacy replace the tops with alternatives that are easier to open. D) Have the patient approach her primary care provider to explore medication alternatives.

C The patient's pharmacy will likely be able to facilitate a practical solution that preserves the patient's independence while still fostering adherence to treatment.

A nurse is educating a patient 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

C 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 patient with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the patient has understood health education when the patient 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."

C Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Patients should be encouraged to pace activities and plan rest periods.

A nurse is creating a teaching plan for a patient who has a recent diagnosis of scleroderma. What topics should the nurse address during health education? Select all that apply. A) Surgical treatment options B) The importance of weight loss C) Managing Raynaud's-type symptoms D) Smoking cessation E) The importance of vigilant skin care

C,D,E Patient teaching for the patient with scleroderma focuses on management of Raynaud's phenomenon, smoking cessation, and meticulous skin care. Surgical treatment options do not exist and weight loss is not a central concern.

A patient is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows that which of the following procedures will be involved? A) Angiography B) Myelography C) Paracentesis D) Arthocentesis

D (Arthrocentesis involves needle aspiration of synovial fluid. Angiography is an x-ray study of circulation with a contrast agent injected into a selected artery. Myelography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Paracentesis is removal of fluid (ascites) from the peritoneal cavity through a small surgical incision or puncture made through the abdominal wall under sterile conditions.)

A nurse is assessing a patient with rheumatoid arthritis. The patient expresses his intent to pursue complementary and alternative therapies. What fact should underlie the nurse's response to the patient? A) New evidence shows CAM to be as effective as medical treatment. B) CAM therapies negate many of the benefits of medications. C) CAM therapies typically do more harm than good. D) Evidence shows minimal benefits from most CAM therapies.

D A recent systematic review of complementary and alternative medicine (CAM) examined the efficacy of herbal medicine, acupuncture, Tai chi and biofeedback for the treatment of rheumatoid arthritis and osteoarthritis. Although acupuncture treatment for pain management showed some promise, in all modalities the evidence was ambiguous. There is not enough evidence of the effectiveness of CAM and more rigorous research is needed.

A patient is diagnosed with giant cell arteritis (GCA) and is placed on corticosteroids. A concern for this patient is that he will stop taking the medication as soon as he starts to feel better. Why must the nurse emphasize the need for continued adherence to the prescribed medication? A) To avoid complications such as venous thromboembolism B) To avoid the progression to osteoporosis C) To avoid the progression of GCA to degenerative joint disease D) To avoid complications such as blindness

D The nurse must emphasize to the patient the need for continued adherence to the prescribed medication regimen to avoid complications of giant cell arteritis, such as blindness.

A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid arthritis (RA). On what aspect of the patient's health should the nurse focus most closely during the visit? A) The patient's understanding of rheumatoid arthritis B) The patient's risk for cardiopulmonary complications C) The patient's social support system D) The patient's functional status

D The patient's functional status is a central focus of home assessment of the patient with RA. The nurse may also address the patient's understanding of the disease, complications, and social support, but the patient's level of function and quality of life is a primary concern.

A nurse is providing care for a patient who has a recent diagnosis of giant cell arteritis (GCA). What aspect of physical assessment should the nurse prioritize? A) Assessment for subtle signs of bleeding disorders B) Assessment of the metatarsal joints and phalangeal joints C) Assessment for thoracic pain that is exacerbated by activity D) Assessment for headaches and jaw pain

D - Assessment of the patient 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).

Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for this patient knows to assess the patient for bone marrow suppression, which may be manifested by which of the following diagnostic findings? A) Hyperuricemia B) Increased erythrocyte sedimentation rate C) Elevated serum creatinine D) Decreased platelets

D - 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 nurse's 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 Exercise is vital to the management of rheumatic disorders. Goals should be preserving and promoting mobility and joint function while limiting stress on the joint and possible damage. Cardiovascular exertion should remain within age-based limits and individual ability, but it is not a goal to minimize exertion. Increasing joint size is not a valid goal.

A 40-year-old woman was diagnosed with Raynaud's phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The patient 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

D Scleroderma starts insidiously with Raynaud's 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.

most common form of inflammatory arthritis.

Gout

A patient with an acute exacerbation of arthritis is temporarilyconfined to bed. What position can the nurse recommend to preventflexion deformities? a. Prone b. Semi-Fowler's c. Side-lying with pillows supporting the shoulders and legs d. Supine with pillows under the knees

It is best for the client with rheumatoid arthritis to lie prone several times daily to prevent hip flexion contracture.

The most common symptom of rheumatic disease that causes a patient to seek medical attention is ________

PAIN

Diffuse Connective Tissue Diseases INCLUDE:

RA, SLE, scleroderma, polymyositis, Sjögren's syndrome, polymyalgia rheumatica (PMR), and giant cell arteritis (GCA).

A client with rheumatoid arthritis has infiltration of the lacrimal and salivary glands with lymphocytes as a result of the disease. What does the nurse understand that this clinical manifestation is? a) Sicca syndrome b) Episcleritis c) Cataracts d) Glaucoma

Sicca syndrome Explanation: Sicca syndrome is a condition of dry eyes and dry mouth that can result from infiltration of the lacrimal and salivary glands with lymphocytes. Episcleritis is an inflammatory condition of the connective tissue between the sclera and conjunctiva. Glaucoma results from increased intraocular pressure, and cataracts are a clouding of the lens in the eye. pg.1072

A patient is taking nonsteroidal anti-inflammatory drugs (NSAIDs)for the treatment of osteoarthritis. What education should the nursegive the patient about the medication? a. Take the medication on an empty stomach in order to increaseeffectiveness b. Since the medication is able to be obtained over the counter, it hasfew side effects c. Take the medication with food to avoid stomach upset

Take the medication with food to avoid stomach upset

________________ (Tylenol) may be appropriate and worth trying before other medications that pose a greater chance of side effects. NSAIDs can be used; however, studies report that long-term use of NSAIDs can increase the risks of peptic ulcers, hemorrhage and cardiovascular toxicity.

a Nonnarcotic analgesic antipyretic -Acetaminophen

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis? a) "My finger joints are oddly shaped." b) "I have pain in my hands." c) "My legs feel weak." d) "I have trouble with my balance."

a) "My finger joints are oddly shaped." Explanation: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities. pg.1066

The nurse is teaching a patient about her rheumatic disease. What statement best helps to explain "autoimmunity"? a) "Your symptoms are a result of your body attacking itself." b) "You are not immune to the disease causing the symptoms." c) "You have inherited your parent's immunity to the disease." d) "You have antigens to the disease, but it they do not prevent the disease."

a) "Your symptoms are a result of your body attacking itself." Correct Explanation: In autoimmunity, the body mistakes its own tissue for foreign tissue and begins to attack it. Symptoms develop as the body destroys tissue. The body is in effect "attacking itself." The other statements do not explain autoimmunity. pg.1055

Which of the following suggests to the nurse that the client with systemic lupus erythematous is having renal involvement? a) Hypertension b) Chest pain c) Behavioral changes d) Decreased cognitive ability

a) Hypertension Explanation: Hypertension is suggestive of renal damage in the client with systemic lupus erythematous. pg.1070

A patient with rheumatoid arthritis is complaining of joint pain. What intervention is a priority to assist the patient? a) Nonsteroidal anti-inflammatory drugs (NSAIDs) b) Opioid therapy c) Surgery d) Ice packs

a) Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment for rheumatoid arthritis pain. They help to decrease inflammation in the joints. Heat is used to relieve pain rather than ice packs. Paraffin baths may also help. Surgery is reserved for joint replacement when the joint is no longer functional. It is not an intervention specific to relieving pain. pg.1056

A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to: a) combat inflammation. b) prevent platelet aggregation. c) promote diuresis. d) prevent infection.

a) combat inflammation. Explanation: Corticosteroids are used to combat inflammation in a child with SLE. To prevent infection, the physician would order antibiotics. Aspirin is used to prevent platelet aggregation. Diuretics, not corticosteroids, promote diuresis. pg.1071

RA inflammatory processes have also been implicated in ___________stiffness and endothelial dysfunction. It is now believed that cardiovascular risks are similar to the risks of patients with diabetes. Therefore, cardiovascular risk assessment should be included in the patient's physical assessment

arterial wall

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan? a) "Exposure to sunlight will help control skin rashes." b) "Monitor your body temperature." c) "Corticosteroids may be stopped when symptoms are relieved." d) "There are no activity limitations between flare-ups."

b) "Monitor your body temperature." Explanation: The nurse should instruct the client to monitor body temperature. Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation. pg.1071

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? a) Performing meticulous skin care b) Administering ordered analgesics and monitoring their effects c) Providing comprehensive client teaching; including symptoms of the disorder, treatment options, and expected outcomes d) Supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware

b) Administering ordered analgesics and monitoring their effects Explanation: An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management her priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions don't not take priority over pain management. pg.1066

The immune abnormalities that characterize systemic lupus erythematosus (SLE) include which of the following? Select all that apply. a) Autoantibodies immune complexes b) Susceptibility c) Damage d) Abnormal innate and adaptive immune responses e) Inflammation

b) Susceptibility d) Abnormal innate and adaptive immune responses a) Autoantibodies immune complexes e) Inflammation c) Damage Explanation: The immune abnormalities that characterize SLE occur in five phases: susceptibility, abnormal innate and adaptive immune responses, autoantibodies immune complexes, inflammation, and damage.

A physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis? a) Increased total serum complement levels b) Negative antinuclear antibody test c) An above-normal anti-deoxyribonucleic acid (DNA) test d) Negative lupus erythematosus cell test

c) An above-normal anti-deoxyribonucleic acid (DNA) test Explanation: Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE. pg.1070

Which of the following would be consistent with the diagnosis of rheumatoid arthritis? a) Increased C4 complement component b) Increased red blood cell count c) Cloudy synovial fluid d) Decreased ESR

c) Cloudy synovial fluid Explanation: In a patient with rheumatoid arthritis, Arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement. pg.1066

A patient is receiving gold sodium thiomalate (Myochrysine) for the treatment of RA. What does the nurse understand about the action of this compound? a) Inhibits DNA synthesis b) Inhibits lysosomal enzymes c) Inhibits T- and B-cell activity d) Inhibits platelet aggregation

c) Inhibits T- and B-cell activity Explanation: Gold sodium thiolmalate (Myochrysine) inhibits T- and B-cell activity, thereby suppressing synovitis during the active stage of rheumatoid disease. pg.1060

Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)? a) Disease-modifying antirheumatic drugs (DMARDS) b) Glucocorticoids c) Nonsteroidal anti-inflammatory drugs (NSAIDs) d) Tumor necrosis factor (TNF) blockers

c) Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: In most patients NSAIDs usually are the first choice in the treatment of RA. The use of traditional NSAIDs and salicylates inhibit the production of prostaglandins and provide anti-inflammatory effects as well as analgesic. In RA, if joint symptoms persist despite use of NSAIDs, the second major drug group known as DMARDs is initiated early in the disease. TNF blockers interfere with the action of tumor necrosis factor (TNF). Oral glucocorticoids, such as prednisone and prednisolone, are indicated for patients with generalized symptoms. pg.1056

Which diagnostic study finding is decreased in patients diagnosed with rheumatoid arthritis? a) Uric acid b) Creatinine c) Red blood cell count d) Erythrocyte sedimentation rate (ESR)

c) Red blood cell count Explanation: There is a decreased red blood cell count in patients diagnosed with rheumatic diseases. ESR increases inflammatory connective tissue disease. Uric acid is increased in gout. Increased creatinine may indicate renal damage in SLE, scleroderma, and polyarteritis. pg.1066

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

c) Safe exercise d) Medication dosages and side effects e) Assistive devices Correct Explanation: The patient who is being discharged to home needs information on how to exercise safely to maintain joint mobility. Medication doses and side effects are always an essential part of discharge teaching. Assistive devices, such as splints or even walkers and canes, may assist the patient to care safely for him- or herself. Narcotics are not commonly used and there would be no reason for dressings. pg.671

After teaching a group of students about systemic lupus erythematosus, the instructor determines that the teaching was successful when the students state which of the following? a) The symptoms are primarily localized to the skin but may involve the joints. b) This disorder is more common in men in their thirties and forties than in women. c) The belief is that it is an autoimmune disorder with an unknown trigger. d) It has very specific manifestations that make diagnosis relatively easy.

c) The belief is that it is an autoimmune disorder with an unknown trigger. Explanation: Systemic lupus erythematosus is believed to be an autoimmune disorder but the triggering mechanism is not known. The disorder is more common in women than in men, most with the disorder in the 3rd or 4th decade of life. The disease is considered the "great imitator" because the clinical signs resemble many other conditions. SLE is a diffuse connective tissue disease that affects multiple body systems. pg.1069

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? a) "OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints." b) "OA is more common in women. RA is more common in men." c) "OA affects joints on both sides of the body. RA is usually unilateral." d) "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."

d) "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Explanation: OA is a degenerative arthritis, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. OA may occur in one hip or knee and not the other, whereas RA commonly affects the same joints bilaterally. RA is more common in women; OA affects both sexes equally. pg.1075

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain? a) Acupuncture b) Cold therapy c) Heat therapy and nonsteroidal anti-inflammatory medications (NSAIDs) d) An exercise routine that includes range-of-motion (ROM) exercises

d) An exercise routine that includes range-of-motion (ROM) exercises Explanation: Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain. pg.1067

A nurse assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)? a) Photosensitivity, polyarthralgia, and painful mucous membrane ulcers b) Weight gain, hypervigilance, hypothermia, and edema of the legs c) Hypothermia, weight gain, lethargy, and edema of the arms d) Facial erythema, pericarditis, pleuritis, fever, and weight loss

d) Facial erythema, pericarditis, pleuritis, fever, and weight loss Explanation: An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE. pg.1070

cytokines

proteins that can be produced by leukocytes that are vital to regulation of hematopoiesis, apoptosis, and immune responses

A client has had several diagnostic tests to determine if he has systemic lupus erythematosus (SLE). What result is very specific indicator of this diagnosis? a) Positive Anti-Sm antibodies b) Positive ANA titre c) Elevated ESR d) Positive Anti-dsDNA antibody test

d) Positive Anti-dsDNA antibody test Explanation: Anti-double-stranded DNA (anti-dsDNA) antibody test is a test that shows high titers of antibodies against native DNA. This is very specific for SLE because this test is not positive for other autoimmune disorders. Anti-Smith (anti-Sm) antibodies are specific for SLE, but are found in only 20% to 30% of clients with SLE. ANA titre shows the presence of an autoimmune disease but is not specific to SLE. The other lab studies may also indicate multisystem involvement. pg.1071

numerous disorders affecting skeletal muscles, bones, cartilage, ligaments, tendons, and joints

rheumatic diseases

A patient is suspected of having myositis. The nurse prepares thepatient for what procedure that will confirm the diagnosis? a. Bone scan b. Computed tomography (CT) c. Magnetic resonance imaging (MRI) d. Muscle biopsy

d. Muscle biopsy - An electromyogram is performed to rule out degenerative muscle disease. - A muscle biopsy may reveal inflammatory infiltrate in the tissue. - Serum studies indicate increased muscle enzyme activity.

a patient has difficulty combing the hair, reaching overhead, and using stairs

polymyositis

Once the diagnosis of RA is made, treatment should begin with either a nonbiologic or biologic DMARD. The goal of using DMARD therapy is

preventing inflammation and joint damage.

problems caused by rheumatic diseases include:

- limitations in mobility and activities of daily living - pain, fatigue, altered self-image - sleep disturbances, as well as systemic effects that can lead to organ failure and death.

Azathioprine (Imuran) has been prescribed for the client with severe rheumatoid arthritis. The dose prescribed is 2 mg/kg/day orally in two divided doses. The medication available is a 50-mg scored tablet. The client weighs 110 pounds. How many milligrams will the nurse prepare per dose for the client?

The client weighs 50 kg (110 lbs/2.2 lbs per kg). The client will receive 100 milligrams per day (50 kg x 2 milligrams/kg). The medication is to be given in two divided doses or 50 mg per dose. pg.1060

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. She asks which of the tests ordered will determine if she is positive for the disorder. Which statement by the nurse is most accurate? a) "You should discuss that matter with your physician." b) "Tell me more about your concerns about this potential diagnosis." c) "The diagnosis won't be based on the findings of a single test but by combining all data found." d) "SLE is a very serious systemic disorder."

c) "The diagnosis won't be based on the findings of a single test but by combining all data found." Explanation: There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the physician, stating that SLE is a serious systemic disorder, and asking the client to express her feelings about the potential diagnosis don't answer the client's question. pg.1070

Which of the following classifications are considered antiarthritic drugs? Select all that apply. a) Disease-modifying antirheumatics (DMARDs) b) Diuretics c) Anti-inflammatory d) Muscle relaxants e) Glucocorticoids

c) Anti-inflammatory a) Disease-modifying antirheumatics (DMARDs) e) Glucocorticoids Explanation: Antiarthritic drugs fall into three major groups: nonsteroidal anti-inflammatory drugs (NSAIDs), DMARDs, and glucocorticoids. Diuretics and muscle relaxants are not antiarthritic drugs. pg.1056

Ms. Wilson is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). You are teaching her and her family information about managing her disease. All of the following would be included, except? a) Avoid sunlight and ultraviolet radiation. b) Maintain a well-balanced diet and increase fluid intake to raise energy levels and promote tissue healing. c) If you have problems with a medication, you may stop it until your next physician visit. d) Pace activities.

c) If you have problems with a medication, you may stop it until your next physician visit. Explanation: Take medications exactly as directed and do not stop the medication if symptoms are relieved unless advised to do so by the physician. Sunlight tends to exacerbate the disease. Because fatigue is a major issue, allow for adequate rest, along with regular activity to promote mobility and prevent joint stiffness. Maintain a well-balanced diet and increase fluid intake to raise energy levels and promote tissue healing. pg.1072

The client with rheumatoid arthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care? a) Reports decreased joint pain b) Reports ability to perform ADLs c) Reports increased fatigue d) Shows a weight gain of 2 pounds

c) Reports increased fatigue Explanation: Fatigue is common with rheumatoid arthritis. Finding a balance between activity and rest is an essential part of the therapeutic regimen. pg.1063

A client is diagnosed with systemic lupus erythematosus (SLE). Which of the following would be most appropriate for the nurse to use to evaluate the client's stage of disease? a) Auscultate the client's lung sounds. b) Observe the client's gait. c) Review the client's medical record. d) Inspect the client's mouth.

c) Review the client's medical record. Explanation: The nurse evaluates the stage of SLE and plans appropriate interventions by reviewing the medical record and diagnostic findings of the client. The stage of the disease cannot be established by observing the client's gait, inspecting the client's mouth, or auscultating the client's lung sounds. pg.1070

After teaching a class comparing rheumatoid arthritis and osteoarthritis, the instructor determines that the teaching was successful when the students identify which of the following as characteristic of osteoarthritis? a) Swan neck deformity b) Ulnar deviation c) Boutonniere deformity d) Heberden nodes

d) Heberden nodes Explanation: Heberden nodes are a characteristic finding of osteoarthritis. Swan neck deformity, boutonniere deformity, and ulnar deviation are characteristic of rheumatoid arthritis. pg.1066

A patient comes to the clinic with an inflamed wrist. How should the nurse splint the joint to immobilize it? a) Extension b) Internal rotation c) Hyperextension d) Slight dorsiflexion

d) Slight dorsiflexion Explanation: Devices such as braces, splints, and assistive devices for ambulation (e.g., canes, crutches, walkers) ease pain by limiting movement or stress from putting weight on painful joints. Acutely inflamed joints can be rested by applying splints to limit motion. Splints also support the joint to relieve spasm. pg.1056