12) Chapter 20 Care of Patients with Arthritis and Other Connective Tissue Diseases

The nurse writes a diagnosis of "potential for fluid volume deficit related to bleeding" for a client diagnosed with DIC. Which would be an appropriate goal? 1. The client's clot formations will resolve in two days 2. The saturation of the client's dressings will be documented 3. The client will use lemon-glycerin swabs for oral care 4. The client's urine output will be > 30 mL per hour

4. The problem is addressing the potential for hemorrhage, and a urine output of greater than 30 mL/hr indicates the kidneys are being adequately perfused and the body is not in shock.

In a severely anemic patient, the nurse would expect to find: a. dyspnea and tachycardia b. cyanosis and pulmonary edema c. cardiomegaly and pulmonary fibrosis d. ventricular dysrhythmias and wheezing

A - Patients with severe anemia (hemoglobin level, less than 6 g/dL) exhibit the following cardiovascular and pulmonary manifestations: tachycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angina, heart failure, myocardial infarction, tachypnea, orthopnea, and dyspnea at rest.

When caring for a patient with thrombocytopenia, the nurse instructs the patient to: a. dab his or her nose instead of blowing b. be careful when shaving with a safety razor c. continue with physical activities to stimulate thrombopoiesis d. avoid Aspirin (ASA) because it may mask the fever that occurs with thrombocytopenia

A - Patients with thrombocytopenia should avoid aspirin because it reduces platelet adhesiveness, which contributes to bleeding. Patients should not perform vigorous exercise or lift weights. If a patient is weak and at risk for falling, supervise the patient when he or she is out of bed. Blowing the nose forcefully should be avoided. The patient should gently pat the nose with a tissue if needed. Instruct patients not to shave with a blade; an electric razor should be used.

Nursing interventions for a patient with severe anemia related to peptic ulcer disease include (select all that apply): a. monitoring stools for guaiac b. instructions for high-iron diet c. taking vital signs every 8 hours d. teaching self-injection of erythropoietin e. administration of cobalamin (vitamin B12) injections

A, B - Stool guaiac test is performed to determine the cause of iron-deficiency anemia that is related to gastrointestinal bleeding. Iron is increased in the diet. Teach the patient which foods are good sources of iron. If nutrition is already adequate, increasing iron intake by dietary means may not be practical. The patient with iron deficiency related to acute blood loss may require a transfusion of packed red blood cells (RBCs).

The nursing management of a patient in sickle cell crisis incudes (select all that apply): a. monitoring CBC b. optimal pain management and O2 therapy c. blood transfusions if required and iron chelation d. rest as needed and deep vein thrombosis prophylaxis e. administration of IV iron and diet high in iron content

A, B, C, D - Complete blood count (CBC) is monitored. Infections are common with elevated white blood cell counts, and anemia may occur with low hemoglobin levels and low RBC counts. Oxygen may be administered to treat hypoxia and control sickling. Rest may be instituted to reduce metabolic requirements, and prophylaxis for deep vein thrombosis (with anticoagulants) is prescribed. Transfusion therapy is indicated when an aplastic crisis occurs. Patients may require iron chelation therapy to reduce transfusion-produced iron overload. Pain occurring during an acute crisis is usually undertreated; patients should have optimal pain control with opioid analgesics, nonsteroidal antiinflammatory agents, antineuropathic pain medications, local anesthetics, or nerve blocks.

The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will have which common condition? A. Dry eyes B. Abdominal bloating after eating C. Excessive production of saliva in the mouth D. Intermittent episodes of diarrhea

A. Dry eyes Rationale A. Clients with Sjögren's syndrome experience dry eyes (keratoconjunctivitis [KCS]). B. Abdominal bloating is not a common report of clients with Sjögren's syndrome. C. Excessive saliva production is not a common report of clients with Sjögren's syndrome. However, dry mouth is commonly described. D. Diarrhea is not a common report of clients with Sjögren's syndrome.

Before administering low-molecular weight heparin (LMWH) to the older adult client after total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3. What action is most important for the nurse to take? A. Notify the health care provider of the platelet count. B. Administer the prescribed LMWH on schedule. C. Assess the activated partial thromboplastin time (aPTT). D. Assess the international normalized ratio (INR).

A. Notify the health care provider of the platelet count. Rationale A. If the platelet count falls below 20,000/mm3, spontaneous bleeding could occur. Notifying the health care provider before the LMWH is given is essential. B. LMWH can cause thrombocytopenia. C. The aPTT is not affected by LMWH. D. Usually, LMWH is given in a low prophylactic dose and does not affect the INR.

Which drug is not appropriate to treat the disease with which it is matched? A. Rheumatoid arthritis—allopurinol (Zyloprim) B. Osteoarthritis—celecoxib (Celebrex) C. Acute gout—colchicine (Colsalide) D. Systemic lupus erythematosus—prednisone (Deltasone)

A. Rheumatoid arthritis—allopurinol (Zyloprim) Rationale A. Allopurinol (Zyloprim) is commonly prescribed to treat gout. The other drug/disease combinations are all correct.

Which instructions for joint protection will the nurse recommend for the client with a connective tissue disease? Select all that apply. A. Use long-handled devices, such as a reacher. B. When getting out of bed, use fingers to push off. C. Sit in a low-back chair. D. Bend at the waist while keeping the back straight. E. Use adaptive devices such as Velcro closures. F. Turn a doorknob clockwise.

A. Use long-handled devices, such as a reacher. E. Use adaptive devices such as Velcro closures. Rationale When getting out of bed, do not push off with fingers, but use the entire palm of both hands.

2. Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include a. a hematocrit (Hct) of 38%. b. an RBC count of 4,500,000/L. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.

When obtaining assessment data from a patient with a microcytic, hypochromic anemia, the nurse would question the patient about: a. folic acid intake b. dietary intake of iron c. a history of gastric surgery d. a history of sickle cell anemia

B Iron-deficiency anemia is a microcytic, hypochromic anemia.

An older woman had a left total hip arthroplasty yesterday afternoon. Which precautions will the nurse teach before helping the client transfer from the bed to the chair? Select all that apply. A. "Stand on your left leg and pivot to the chair." B. "Do not hyperflex your hips when sitting." C. "Cross your legs to be more comfortable." D. "Avoid twisting your body when moving." E. "Use your cane to help move into the chair."

B. "Do not hyperflex your hips when sitting." D. "Avoid twisting your body when moving." E. "Use your cane to help move into the chair." Rationale Appropriate care after a left total hip arthroplasty includes proper alignment through correct positioning, keeping the leg slightly abducted and preventing flexion beyond 90 degrees, and preventing rotation. Ambulatory aids such as canes and walkers will be used when transferring or ambulating. The client should avoid rotation of the hip when moving and transferring. Crossing the legs prevents the client from maintaining proper alignment; legs should not be crossed beyond the midline of the body.

Before administering prednisone IV push to the middle-aged adult with rheumatoid arthritis (RA), the nurse notes that the client's random Accu-Chek is 139. Which action is most important for the nurse to take? A. Instruct the client to drink diet soda to prevent elevation of blood sugar. B. Administer the prescribed prednisone on schedule. C. Notify the health care provider of the random Accu-Chek result. D. Review the client's antinuclear antibody (ANA) level.

B. Administer the prescribed prednisone on schedule. Rationale A. Blood sugar is only slightly elevated. Encourage fluids other than soda, diet or otherwise. B. For this client, giving the medication per schedule is essential in treating the disease. The Accu-Chek value will be monitored regularly because the client is receiving prednisone. C. Accu-Cheks are performed and parameters are set as to when the health care provider should be notified, but usually this is done only if the random Accu-Chek is greater than 150. D. This is not required before prednisone is given. The client's ANA is elevated because of the RA.

Which factor indicates to the nurse the only similarity between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)? A. Feeling tired and having a temperature that runs about 100° F (37.8° C) during the day B. Disfiguring and embarrassing rash C. Peripheral neuropathies and cranial nerve palsies D. High risk for renal inflammation

B. Disfiguring and embarrassing rash Rationale A. Fatigue and fever are common only to SLE. B. Skin lesions are common to SLE and DLE. C. Neurologic manifestations are common in SLE. D. Inflammation of the kidneys is common in SLE.

Which assessment findings will the nurse expect for the client with late-stage rheumatoid arthritis? Select all that apply. A. Heberden's nodes B. High erythrocyte sedimentation rate (ESR) values C. Positive antinuclear antibody (ANA) titer D. Subcutaneous nodules E. Anemia F. Red, swollen joints

B. High erythrocyte sedimentation rate (ESR) values C. Positive antinuclear antibody (ANA) titer D. Subcutaneous nodules E. Anemia F. Red, swollen joints Rationale Clients with rheumatoid arthritis generally have an elevated ESR, positive ANA, and subcutaneous nodules, and they may develop anemia as a complication. Heberden's nodes are commonly seen in osteoarthritis.

The nurse is reviewing laboratory results for the client with symptoms of rheumatoid arthritis (RA)? Which laboratory finding indicates to the nurse that the client may have rheumatoid arthritis? A. Total serum complement, 75 units/mL B. Positive total antinuclear antibody (ANA) C. Erythrocyte sedimentation rate (ESR), 20 mm/hr D. Beta-globulin level, 1.0 g/dL

B. Positive total antinuclear antibody (ANA) Rationale A. This is the normal range for total serum complement. B. Elevation of total ANA is common in systemic lupus erythematosus (SLE), systemic sclerosis (SSc), and RA. C. This is a normal ESR for a female. D. This is a normal beta-globulin level.

The client diagnosed with exacerbation of systemic sclerosis (SSc) asks the nurse why a foot board and a bed cradle have been placed on the bed. The nurse explains that the foot board and the bed cradle are used for what purpose? A. To inspect skin for lesions or changes B. To promote comfort from Raynaud's phenomenon C. To prevent foot drop and contractures D. To decrease chilling of the extremities

B. To promote comfort from Raynaud's phenomenon Rationale A. Skin ulcers and lesions can occur with SSc. A foot board and a bed cradle do not assist with skin inspection. B. Acute pain occurs during Raynaud's phenomenon (the first symptom that occurs with SSc), and avoiding pressure from bed linens is a comfort measure. C. Bed cradles do not prevent foot drop or contractures. Only foot boards do this. D. Decreased chilling and reduced vasospasms can be accomplished by increasing the room temperature.

The nurse is aware that a major difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that: a. Hodgkin's lymphoma occurs only in young adults b. Hodgkin's lymphoma is considered potentially curable c. non-Hodgkin's lymphoma can manifest in multiple organs d. non-Hodgkin's lymphoma is treated only with radiation therapy

C - Non-Hodgkin's lymphoma can originate outside the lymph nodes, the method of spread can be unpredictable, and most affected patients have widely disseminated disease.

The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select? a. Roast beef, gelatin salad, green beans, and peach pie b. Chicken salad sandwich, coleslaw, French fries, ice cream c. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie d. Pork chop, creamed potatoes, corn, and coconut cake

C Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not

What health teaching by the nurse is the most important for clients diagnosed with discoid lupus erythematosus and managing the disease using topical steroid cream? A. "Take calcium supplements to prevent osteoporosis from the steroid." B. "Stay away from crowds and people with infections." C. "Avoid being in the sun to prevent disease flare-ups." D. "Use heavy powder makeup to cover skin lesions."

C. "Avoid being in the sun to prevent disease flare-ups." Rationale Teach clients techniques to protect the skin. Instruct clients to avoid prolonged exposure to sunlight and other forms of ultraviolet lighting, including certain types of fluorescent light. Remind them to wear long sleeves and a large-brimmed hat when outdoors. Clients should use sun-blocking agents with a sun protection factor (SPF) of 30 or higher on exposed skin surfaces. Side effects from topical steroid creams include thin skin, red lesions, and acne. Immunosuppression and calcium loss are associated with oral, not topical, steroids. Excess powder and other drying substances should be avoided; cosmetics must be carefully selected.

Which statement indicates to the nurse that the client with fibromyalgia syndrome is using a complementary therapy to help relieve symptoms? A. "My Thera-Band really helps me loosen up my arms." B. "The brace on my lower leg is helping me walk better." C. "Focusing on the slow stretching movements and my breathing in tai chi helps me relax." D. "Water aerobic exercises have helped me sleep better."

C. "Focusing on the slow stretching movements and my breathing in tai chi helps me relax." Rationale A. Thera-Band exercises are used in physical therapy. B. Splints or braces are used in occupational therapy. C. Tai chi is an alternative or complementary therapy that focuses on slow and gentle stretching movements and breathing. D. This is an example of a low-impact exercise, not alternative therapy.

The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies? A. "I'm letting my husband do most of the cooking, but I help plan the menus." B. "Since I started taking etanercept (Enbrel), I can walk up and down the stairs of my home easier." C. "My husband is getting used to having sexual intercourse only once a month." D. "I worry about what's going to happen to me if my husband cannot take care of me, but my husband says he will hire someone if he has to."

C. "My husband is getting used to having sexual intercourse only once a month." Rationale A. Being involved in the meal process is a productive coping strategy. B. This statement indicates productive coping because it describes improved mobility. C. This could indicate negative body image or depression. Additional open-ended questions by the nurse are required. D. Expressing concerns but then identifying a plan is a productive coping strategy.

The client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy? A. "Drinking alcoholic beverages should be avoided." B. "The health care provider should be notified 3 months before a planned pregnancy." C. "Rheumatrex should be taken at mealtimes." D. "I will avoid any live vaccines."

C. "Rheumatrex should be taken at mealtimes." Rationale A. Alcoholic beverages increase the risk for hepatotoxicity; this statement indicates the client understood the teaching. B. Strict birth control is recommended for any client of childbearing age because of the possibility of birth defects; this statement indicates the client understood the teaching. C. Rheumatrex should be taken 1 hour before or 2 hours after a meal; this statement indicates the client needs further teaching. D. Severe reactions may occur when live vaccines are given because of the immunosuppressive effect of Rheumatrex; this statement indicates the client understood the teaching.

The client who recently has had a total hip arthroplasty is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? A. Use an abduction pillow between the legs. B. Keep heels off the bed. C. Avoid using a straight razor. D. Reorient frequently.

C. Avoid using a straight razor. Rationale A. This is usually done immediately after surgery, especially if the client is confused or restless and cannot maintain proper joint positioning. B. This prevents pressure ulcers during the in-hospital postoperative period. C. The client will be on anticoagulants for 4 to 6 weeks at home and should avoid any injury to the skin, including when shaving. D. Changes in mental status can occur immediately after surgery as a result of anesthesia.

A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client? a. Side-lying with knees flexed b. Knee-chest c. High Fowler's with knees flexed d. Semi-Fowler's with legs extended on the bed

D

Multiple drugs are often used in combinations to treat leukemia and lymphoma because: a. there are fewer toxic side effects b. the chance that one drug will be effective is increased c. the drugs are more effective without causing side effects d. the drugs work by different mechanisms to maximize killing of malignant cells

D - Combination therapy is the mainstay of treatment for leukemia. The three purposes for using multiple drugs are to (1) decrease drug resistance, (2) minimize the drug toxicity to the patient by using multiple drugs with varying toxic effects, and (3) interrupt cell growth at multiple points in the cell cycle.

When caring for a patient with thrombocytopenia, the nurse instructs the patient to: a. dab his or her nose instead of blowing b. be careful when shaving with a safety razor c. continue with physical activities to stimulate thrombopoiesis d. avoid Aspirin (ASA) because it may mask the fever that occurs with thrombocytopenia A - Patients with thrombocytopenia should avoid aspirin because it reduces platelet adhesiveness, which contributes to bleeding. Patients should not perform vigorous exercise or lift weights. If a patient is weak and at risk for falling, supervise the patient when he or she is out of bed. Blowing the nose forcefully should be avoided. The patient should gently pat the nose with a tissue if needed. Instruct patients not to shave with a blade; an electric razor should be used. The nurse would anticipate that a patient with von Willebrand disease undergoing surgery would be treated with administration of vWF and: a. thrombin b. factor VI c. factor VII d. factor VIII

D - von Willebrand disease involves deficiency of the von Willebrand coagulation protein, variable factor VIII deficiencies, and platelet dysfunction. Treatment includes administration of von Willebrand factor and factor VIII.

The nurse is teaching the client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching? A. "RA is inflammatory. OA is degenerative." B. "The risk factors or causes of RA are probably autoimmune, whereas OA may be caused by age, obesity, trauma, or occupation." C. "The typical onset of RA is seen between 35 and 45 years of age, whereas the typical onset of OA is seen in clients older than 60 years." D. "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints."

D. "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints." Rationale A. This statement is true and indicates that the client understood. B. Research is being done to find a possible genetic cause for OA, but age, trauma, obesity, and occupation are the main causes of degeneration; this statement indicates the client understood. C. RA occurs most often in women, usually between 35 and 45 years of age, whereas older age is a cause of OA; this statement is true, which indicates the client understood. D. OA is unilateral and usually affects a single joint, whereas RA is bilateral and affects multiple joints; this statement is incorrect, so it indicates that the client needs further teaching.

The nurse is caring for a postoperative client with a total joint arthroplasty. What actions will the nurse take to prevent venous thromboembolism (VTE) postoperatively? Select all that apply. A. Massage the legs. B. Keep the legs slightly abducted. C. Use the knee gatch on the bed. D. Apply elastic stockings. E. Administer anticoagulants.

D. Apply elastic stockings. E. Administer anticoagulants. Rationale Massaging the legs could cause a blood clot to dislodge and should be avoided.

The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis who has been ordered to start sulfasalazine (Azulfidine) therapy? The nurse plans to contact the health care provider if the client has which condition? A. Glaucoma B. Hypertension C. Hypothyroidism D. Sulfa allergy

D. Sulfa allergy Rationale A. Sulfasalazine (Azulfidine) is not contraindicated in clients with glaucoma. B. Sulfasalazine (Azulfidine) is not contraindicated in clients with hypertension. C. Sulfasalazine (Azulfidine) is not contraindicated in clients with hypothyroidism. D. Sulfasalazine (Azulfidine) contains sulfa and is contraindicated in clients with sulfa allergies.

An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator? a. Conjunctiva of the eye b. Soles of the feet c. Roof of the mouth d. Shins

c The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment

The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse? Total bilirubin, 0.3 mg/dL Serum creatinine, 0.5 mg/dL Hemoglobin, 16 g/dL Folate, 1.5 ng/mL

folate, 1.5 the normal folic acid is 1.8-9 normal b12 is 200-900 low folic acid level in presence of a normal vitamin b12 level is indicative of folic acid deficiency anemia