Chapter 18 - Arthritis & other Connective Tissue Diseases

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.)

- Buy and install an elevated toilet seat. - Install grab bars in the shower & by the toilet. - Remove all throw rugs throughout the house. - Use a shower chair while taking a shower.

A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctly matched? (Select all that apply.)

- Colchicine (Colcrys) - Acute gout - Febuxostat (Uloric) - Chronic gout - Indomethacin (Indocin) - Acute gout - Probenecid (Benemid) - Chronic gout

Which assessment findings will the nurse expect for the client with early-stage rheumatoid arthritis? (Select all that apply)

- Elevated erythrocyte sedimentation rate (ESR) - Positive antinuclear antibody (ANA) titer - Joint inflammation - Red, swollen joints

The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

- Keep the room at a comfortably warm temperature. - Place a foot cradle at the end of the bed to lift sheets. - Remind the client to elevate the head of the bed after eating.

What self-management education by the nurse is important for clients diagnosed with systemic lupus erythematosus who are taking prednisone? (Select all that apply)

- Take calcium supplements to prevent osteoporosis from the steroid - Stay away from crowds and people with infections - Avoid being in the sun to prevent disease flare-ups - Take your prednisone early in the morning before breakfast

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first?

Client with a red, hot, swollen right wrist The presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met?

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

A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include?

Avoid large crowds or people who are ill This drug has a Food and Drug Administration black box warning about opportunistic or other serious infections. Teach the client to avoid large crowds and people who are ill.

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first?

Client with a fever and cough who is taking tofacitinib (Xeljanz) Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best?

Consult with the health care provider about administering both drugs to the client. Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain

A nurse is caring for a client with systemic sclerosis. The client's facial skin is very taut, limiting the client's ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate?

Dentist With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist.

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.)

"Avoid acetaminophen in over-the-counter medications." "It may take several weeks to become effective on pain." "Stay away from large crowds and people who are ill." "You may find that folic acid, a B vitamin, reduces side effects."

Which statement indicates to the nurse that a client with fibromyalgia syndrome is using a complementary therapy to help relieve symptoms?

"Focusing on the slow stretching movements and my breathing in tai chi helps me relax." Tai chi is an alternative or complementary therapy that focuses on slow and gentle stretching movements and breathing.

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate?

"Have you been taking glucosamine supplements?" since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use.

The home health nurse conducts a community presentation on Lyme disease for the residents of an assisted-living facility. Which statement from the audience indicates to the home health nurse that further instruction is needed?

"I will gently remove the tick with tissue and then burn it to prevent the spread of the disease." Burning a Lyme disease-carrying tick could spread infection, so flushing it down the toilet is the recommended disposal method; this statement indicates that further instruction is needed.

The nurse is caring for an older adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies?

"The bus is coming to pick me up from the senior center three times a week so I can play cards." Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support.

A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.)

- Allow the client uninterrupted rest time. - Assess the client's usual bedtime routine. - Limit environmental noise as much as possible. - Offer a massage or warm shower at night

The nurse is caring for a postoperative client with total joint arthroplasty. What actions does the nurse take to prevent venous thromboembolism (VTE) postoperatively? (Select all that apply.)

- Apply elastic stockings. - Administer anticoagulants. Support stockings provide compression, which helps prevent VTE. Support stockings provide compression, which helps prevent VTE.

A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.)

Acupuncture Stretching Tai chi

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.)

Antibodies lead to inflammation. It consists of an autoimmune process.

A 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?

Any side effects of this drug will be mild Methotrexate can have devastating side effects and toxic effects, and the client should be carefully monitored when taking this drug; this statement indicates the client needs further clarification.

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Apply an abduction pillow to the client's legs. Place pillows under the heels to keep them off the bed. Take and record vital signs per unit/facility policy.

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.)

Felty's syndrome Joint deformity Weight loss

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important?

Ensure that a consent for transfusion is on the chart. The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed.

Which factor indicates to the nurse the only similarity between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)?

Disfiguring and embarrassing rash Skin lesions are common to SLE and DLE. Fatigue and fever are common only to SLE. Neurologic manifestations and inflammation of the kidneys are common in SLE.

A client had a right total hip arthroplasty 2 days ago. Which precautions will the nurse teach the client to prevent surgical complications? (Select all that apply)

Do not bend your hips more than 90 degrees Avoid twisting your body when moving Use a long-handled shoe horn to put on your shoes

A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate?

Giving subcutaneous injections Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.)

Grab bars to reach high items Long-handled bath scrub brush Toothbrush with built-up handle

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important?

Have adequate help to transfer the client. The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)?

Lose weight if needed. Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs.

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

My husband is getting used to having sex only once a month The client's comment that her husband is getting used to sex only once a month could indicate negative body image or depression; additional open-ended questions by the nurse are required.

A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important?

Providing a verbal hand-off report to the facility As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?

Severe osteoporosis Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted

The health care provider prescribes celecoxib (Celebrex) for a client with osteoarthritis. What health teaching will the nurse provide for this client regarding this drug? (Select all that apply)

Stop taking the drug if unusual bleeding occurs and call your health care provider Report frequent episodes of indigestion to your health care provider Call 911 immediately if chest pain occurs

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse?

Storing the CPM machine under the bed after removal For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.

The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis (RA) who has been ordered to start sulfasalazine (Azulfidine) therapy. The nurse plans to contact the health care provider if the client has which condition?

Sulfa allergy Sulfasalazine contains sulfa and is contraindicated in clients with sulfa allergies.

A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best?

This drug works in the brain to decrease pain Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?

Try a paraffin wax dip 20 minutes before you quilt Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure

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

Use adaptive devices such as Velcro closures Use long-handled devices such as a reacher (Use of long-handled devices such as a reacher and other adaptive devices, such as Velcro closures, helps to protect the joints) (Use of long-handled devices such as a reacher and other adaptive devices, such as Velcro closures, helps to protect the joints)

The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan?

Wear supportive shoes. Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints.

Which population group is most likely to be diagnosed with fibromyalgia syndrome?

Women between 30 and 50 years of age Most patients diagnosed with fibromyalgia syndrome are women between 30 and 50 years of age.

During a health history assessment, a patient with rheumatoid arthritis, chronic hypertension, and diagnosis of a recent cerebrovascular accident states that she takes 2 fish oil capsules (5 g) daily as a supplement for her RA. What additional question(s) should the nurse ask? (Select all that apply.)

- Are you taking anticoagulant medications? - Have you found the fish oil to help your RA? - What other supplements do you currently take? - How long have you been taking fish oil capsules? - Have you notified your physician about taking fish oil capsules?

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberden's nodules. What assessment technique is correct?

Inspect the client's distal finger joints. Herberden's nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the client's distal fingertips.

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?

Acetaminophen (Tylenol) the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

The nurse is preparing to give medications to a group of clients. Which drug is not appropriate to treat the disease with which it is matched?

Acute gout—allopurinol (Zyloprim) Allopurinol is given to clients with chronic gout, not acute gout. All of the other medications are appropriate for the medical diagnoses.

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement?

Administer preoperative antibiotic as ordered. To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery

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

Administer the prescribed prednisone on schedule. For this client, giving the medication per schedule is essential in treating the disease. The blood glucose value will be monitored regularly because the client is receiving prednisone.

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?

Assess medication records for steroid use. Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid.

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best?

Assess neurovascular status in both legs. This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs.

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started "acting up," especially both hips and knees. What action by the nurse is best?

Assess the client for the presence of subcutaneous nodules or Baker's cysts. Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Baker's cysts.

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best?

Assess the client's culture more thoroughly The nurse needs a more thorough understanding of the client's culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions.

A client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver?

Avoid using a straight razor. The client will be on anticoagulants for 4 to 6 weeks at home and should avoid injury to the skin, including when shaving.

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further?

Creatinine 3.9mg/dL Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding.

The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate?

Drink 1 to 2 liters of water each day Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from occurring.

The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will also have which common condition?

Dry eyes Clients with Sjögren's syndrome experience dry eyes (keratoconjunctivitis sicca).

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.)

Dry, scaly skin rash - Systemic lupus erythematosus (SLE) Esophageal dysmotility - Systemic sclerosis Vasculitis causing organ damage - Rheumatoid arthritis

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best?

Help the client create backup plans to minimize disruption. SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control

Assessment findings reveal that an older adult client with severe osteoarthritis of the left hip can no longer perform activities of daily living (ADLs) and has had several falls in the home over the past month. To which community resource does the nurse refer the client?

Home health care agency Home health care referrals can order a nurse to evaluate the home situation and notify the health care provider of any in-home needs, such as an aide, physical therapist, or social worker.

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement?

I always wear long sleeves, pants, and a hat when outdoors Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management?

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

A nursing technician is assigned to care for a client who has a CPM machine in place after a total knee arthroplasty. Which statement by the "tech" indicates a need for further teaching and supervision by the nurse?

I will turn off the machine if the client has any pain If the client has pain, the nurse should ensure that the pain is managed. Removing the CPM machine could cause less range of motion in the knee, which would lead to increased pain during physical therapy.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?

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

The nurse is assessing a patient who has undergone total knee arthroplasty for which continuous femoral nerve blockade was utilized. The nurse notes that the patient is anxious. Vital signs include BP 92/58, HR 62, RR 12, and SpO2 89%. What is the priority nursing intervention?

Notify the Rapid Response Team This patient's vital signs suggest instability, and a Rapid Response Team should be activated immediately

Before administering low-molecular-weight heparin (LMWH) to an 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?

Notify the health care provider of the platelet count. 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. LMWH can cause thrombocytopenia, so it should not be administered when the client's platelet count is low.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery. What action by the nurse is best?

Notify the provider immediately. Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury.

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the client's pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next?

Notify the surgeon or anesthesia provider immediately With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately.

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important?

Notify your provider at once if you get a fever Fever is the classic sign of a lupus flare and should be reported immediately.

Which element is a risk factor for osteoarthritis (OA)?

Obesity Being obese, not thin, places an individual at higher risk for slow joint degeneration and the development of OA.

A client has a possible connective tissue disease and the nurse is reviewing the client's laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select all that apply.)

Positive human leukocyte antigen B27 (HLA-B27) - Reiter's syndrome or ankylosing spondylitis Positive rheumatoid factor - Possible kidney disease

A client has symptoms of rheumatoid arthritis (RA). Which laboratory finding indicates to the nurse that the client may have RA?

Positive total antinuclear antibody (ANA) Elevation of total ANA is common in systemic lupus erythematosus, systemic sclerosis, and RA.

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate?

Prepare to administer epoetin alfa (Epogen). This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the client's red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells

A 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 they are used for what purpose?

Promote comfort from Raynaud's phenomenon Acute pain occurs during Raynaud's phenomenon (the first symptom that occurs with SSc), and avoiding pressure from bed linens is a comfort measure.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed?

Raise the lower siderail on the affected side Because the client's leg is strapped into the CPM, if it falls off the bed due to movement, the client's leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring.

The nurse is teaching a client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching?

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 OA is unilateral and usually affects a single joint, whereas RA is bilateral and affects multiple joints; this statement by the client indicates the need for further teaching.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury?

Use an abduction pillow Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection?

Use aseptic technique for dressing changes. Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjögren's syndrome?

Visual acuity Sjögren's syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur

In teaching a client with acute secondary gout, which instruction about preventing recurrence is most important for the nurse to include?

Weight Watchers has healthy meal plans Crash diets and obesity are causes of secondary gout; avoiding crash diets and keeping fit will prevent recurrence. Eating plenty of fruits and vegetables should be encouraged because they are low in purines, which may reduce the recurrence of gout.