Chapter 19 Connective Tissue Disorders

A patient reports using aspirin for years to control severe arthritis pain because acetaminophen and NSAIDs just dont work well for me. The nurse would advise the patient of which sign of aspirin toxicity? 1. Seeing halos around lights 2. Intermittent red, itchy skin rash 3. Ringing in the ears 4. Ankle edema

3

A patient is newly diagnosed with osteoarthritis. List the nursing diagnoses for this patient in the order of their priority. Choice 1. Imbalanced Nutrition: Less than Body Requirements related to inadequate intake of calcium Choice 2. Risk for Injury related to effects of change in bone structure secondary to osteoarthritis Choice 3. Acute Pain of the Lower Spine related to vertebral compression Choice 4. Deficient Knowledge related to osteoarthritis and treatment to prevent further damage

3, 2, 1, 4

The nurse has been providing care to a patient with scleroderma for a number of years. As the patients disease progresses, the nurse monitors for CREST symptomology. For which finding is the nurse assessing? 1. Recurrence of tophi on the ears or fingers 2. Shiny skin over the involved joints. 3. Development of telangiectasia 4. Extremities that are always cool to the touch

3.

A client has been diagnosed with fibromyalgia. The nurse realizes that which of the following categories of medications have been successful in the treatment of this disorder? (Select all that apply.) 1. Antiarrhythmics 2. Antibiotics 3. Antidepressants 4. Analgesics 5. Calcium channel blockers 6. Muscle relaxants

346

The nurse is instructing a client diagnosed with gout about a low-purine diet. Which of the following foods would be identified as those to avoid when following this diet? (Select all that apply.) 1. Avocados 2. Milk 3. Scallops 4. White bread 5. Alcohol 6. Bacon

356

A 59 year-old female is being evaluated for presence of a connective tissue disease. The erythrocyte sedimentation rate (ESR) result is reported as 26 mm/hour. How would the nurse evaluate this result? 1. The ESR is very low, indicating that the patient has an autoimmune disorder rather than a connective tissue disorder. 2. This is a normal finding, so no connective tissue disease is present. 3. The ESR is high, so inflammatory disease is present. 4. The ESR is normal and other testing is indicated.

4

A client is diagnosed with osteoarthritis. The nurse would not expect to find which of the following during assessment? 1. Bouchards nodes 2. Crepitus 3. Heberdens nodes 4. Symmetrical joint involvement

4

.A client diagnosed with gout is concerned about the formation of nodules. The nurse should explain that these nodules are called: 1. Bouchards nodes. 2. cysts. 3. Heberdens nodes. 4. tophi.

4. A tophus is the characteristic nodule that develops in the patient with gout. A tophus consists of uric acid crystals.

A patient diagnosed with gout is concerned that the small lumps on his ear and big toe will become lodged in his blood, resulting in a blood clot. Which explanation by the nurse is most accurate? 1. Clots will not develop if you take your antigout medicine. 2. Unfortunately, this is a common complication associated with gout. 3. You will need to talk with the physician during your next visit. 4. These lumps do not cause clots.

4. The deposits are known as tophi. They result from uric acid crystal buildup and develop most often in locations with lower body temperature readings. They do not cause clots.

Anakinra (Kineret) is prescribed for a patient who has rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. self-administration of subcutaneous injections. b. taking the medication with at least 8 oz of fluid. c. avoiding concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs). d. symptoms of gastrointestinal (GI) irritation or bleeding.

A

The nurse instructing a patient with rheumatic arthritis about the prescribed exercise program includes that the exercises should be: a. done every day 3 to 10 times for every joint. b. done even if inflammation is present. c. continued past the point of pain. d. doubled the next day if one day is missed.

A

A patient asks the difference between osteoarthritis and rheumatoid arthritis. What manifestations should the nurse explain are characteristic of rheumatoid arthritis? (Select all that apply.) a. Low-grade fever b. Heberdens nodes c. Autoimmune disease d. Activity increases pain e. Early morning stiffness f. Involvement of other major organs

A, C, E, F Rheumatoid arthritis is a systemic autoimmune disease with morning stiffness, low-grade fever, and organ involvement. B. Heberdens nodes are seen in osteoarthritis. D. Pain increases with activity in osteoarthritis.

A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing a side effect of the medication? a. The patients blood glucose is 165 mg/dL. b. The patient has no improvement in symptoms. c. The patient has experienced a recent 5-pound weight loss. d. The patients erythrocyte sedimentation rate (ESR) has increased.

A. Hyperglycemia is a side effect of prednisone.

During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would expect the patient to report (select all that apply)? a. sleep disturbances. b. multiple tender points. c. cardiac palpitations and dizziness. d. multijoint pain with inflammation and swelling. e. widespread bilateral, burning musculoskeletal pain.

ABCE

Which finding will the nurse expect when assessing a 60-year-old patient who has osteoarthritis (OA) of the left knee? a. Heberdens nodules b. Pain upon joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

B

Which information will the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about the management of the condition? a. Exercise by taking long walks. b. Do daily deep breathing exercises. c. Sleep on the side with hips flexed. d. Take frequent naps during the day.

B

When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus (SLE), which result is most important to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

B. The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage

A patient who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that rheumatoid nodules are present on the patients elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injection of the nodule. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodule

C

An 87-year-old female with a history of osteoarthritis reports an average generalized pain score of 4 on a 0-to-10 scale while using acetaminophen prn. Which response about this pain level should the nurse make to the patient? a. Do you take a daily calcium supplement? b. Im glad the acetaminophen is working for you. c. Are you satisfied with this level of pain control? d. Research shows that acetaminophen is not really effective for osteoarthritis pain.

C

When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information is most important to communicate to the health care provider? a. The blood glucose is 75 mg/dL. b. The rheumatoid factor is positive. c. The white blood cell (WBC) count is 1500/mL. d. The erythrocyte sedimentation rate is elevated.

C. Bone marrow suppression is a possible side effect of methotrexate, and the patients low WBC count places the patient at high risk for infection.

To determine whether a patient with joint swelling and pain has systemic lupus erythematosus, which test will be most useful for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

C. The anti-Sm is antibody found almost exclusively in SLE.

CREST syndrome

Calcinosis Raynaud's phenomenon Esophageal dysfunction Sclerodactyly Tenagiectasia (Lupus)

The home health nurse is doing a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed? a. The patient requires a 2-hour midday nap. b. The patient has been taking 16 aspirins daily. c. The patient sits on a stool when preparing meals. d. The patient sleeps with two pillows under the head.

D. The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping.

A client is going to have tender points examined to determine the diagnosis of fibromyalgia. The nurse should instruct the client the number of tender points that must be positive for the diagnosis would be: a. 11 b. 13 c. 15 d. 17

a. 11 The presence of at least 11 of 18 tender points is considered diagnostic for fibromyalgia.

A patient diagnosed with systemic lupus erythematosus exhibits a facial rash. What instruction should the nurse provide regarding skin care? (SATA) 1. Avoid being out of doors during the hours of greatest sun intensity. 2. Use sunscreen if sun exposure is possible. 3. Apply hydrocortisone cream 1% to the rash 4 to 6 times per day. 4. Wash the rash with antibacterial soap three times a day. 5. Swim in a chlorinated pool for relief of burning.

1, 2

A patient diagnosed with scleroderma has been prescribed methotrexate (Rheumatrex). Which medication teaching should the nurse provide? (SATA) 1. Use sunblock when outside. 2. Avoid caffeine. 3. Avoid citrus juices. 4. Do not take aspirin with this drug. 5. Do not use any over-the-counter medication without first checking with the health care provider.

1, 2, 4, 5

A patient diagnosed with scleroderma reports heartburn. Which instructions would the nurse provide for treatment of this symptom? (SATA) 1. Drink only decaffeinated beverages. 2. Use the nicotine patches as prescribed. 3. Increase fiber in the diet. 4. Elevate the head of the bed to 30 degrees. 5. Take omeprazole (Prilosec) as prescribed.

1,2,4,5 Scleroderma can affect the esophagus. Avoidance of caffeine may help alleviate heartburn symptoms.

The nurse would evaluate that a patient with systemic lupus erythematosus understands dietary teaching when the patient selects which food for breakfast? 1. Orange juice 2. Sausage, gravy, and biscuits 3. A doughnut 4. Toast

1. The patient with SLE requires additional vitamin C.

The nurse is assessing a client who is diagnosed with gout. Which of the following findings will the nurse most likely assess in this client? (Select all that apply.) 1. Decreased range of motion 2. Edema in a joint 3. Elevated uric acid levels 4. Pain that develops over many weeks 5. Fever 6. Headache

12356

A patient with rheumatoid arthritis is prescribed infliximab (Remicade). Which nursing diagnosis does the nurse include as priority in the patients plan of care? 1. Risk for Ineffective Tissue Perfusion 2. Risk for Infection 3. Disturbed Body Image 4. Anxiety

2

The nurse is instructing a client diagnosed with osteoarthritis. Which of the following statements indicates that the client understands these instructions? 1. Exercise will not be of help because it will stress my joints. 2. I will need to lose weight; my doctor says about 20 pounds. 3. I will take my medications only if the pain is very bad. 4. I can still go on my marathon shopping trips with my daughter.

2

A patient is receiving a series of diagnostic tests to confirm the diagnosis of osteoarthritis (OA). The nurse would interpret which results as supporting the diagnosis of OA? (SATA) 1. Presence of antinuclear antibodies in blood 2. Asymmetrical joint cartilage loss seen on X-ray 3. Increased erythrocyte sedimentation rate (ESR) in blood 4. Bone spurs visible on computed tomography (CT) 5. Increased bone density in Dexa scan

2,3,4,5 antinuclear antibodies in blood is reflective of RA, not OA.

A patient is experiencing symptoms typical of gout in the right foot. The nurse would prepare the patient for which diagnostic examinations? (SATA) 1. MRI of the affected foot 2. Joint aspiration 3. Serum uric acid level 4. CT of the affected foot 5. X-ray of the affected foot

2,3,5

The nurse has chosen these nursing diagnoses for a patient who has systemic lupus erythematosus. Which NDX would be assigned the highest priority? 1. Skin Integrity: Impaired 2. Activity Intolerance 3. Anxiety 4. Fluid Volume Excess

2.

A client is experiencing an acute attack of gout. The nurse should be prepared to provide which of the following medications as prescribed? 1. Allopurinol 2. Colchicine 3. Probenecid 4. Sulfinpyrazone

2. Colchicine is used for the acute attack phase. The other medications would be used for further treatment of the gout.

A butterfly rash on the face is characteristic of which inflammatory connective tissue disease? 1. Rheumatoid arthritis 2. Systemic lupus erythematosus (SLE) 3. Pagets disease 4. Gout

2. Lupus

The nurse is monitoring a patient diagnosed with scleroderma for the development of sclerodactyly. Which area would the nurse assess? 1. The posterior neck 2. The knees 3. The chest wall 4. The fingers

4. Sclerodactyly is the thickening, induration, and tightening of the skin of the fingers.

Which assessment finding about a patient who has been using naproxen (Naprosyn) for 3 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider? a. The patient has dark colored stools. b. The patients pain has not improved. c. The patient is using capsaicin cream (Zostrix). d. The patient has gained 3 pounds over 3 weeks.

A

Which statement by a 24-year-old woman with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurses teaching about management of the condition? a. I will use a sunscreen whenever I am outside. b. I will try to keep exercising even if I am tired. c. I should take birth control pills to keep from getting pregnant. d. I should not take aspirin or nonsteroidal anti-inflammatory drugs.

A. Severe skin reactions can occur in pts with SLE who are exposed to the sun.

A patient with gout has been instructed on the prescribed medication allopurinol (Zyloprim). Which patient statement indicates understanding of the action of this medication? a. Excretes proteins. b. Blocks formation of uric acid. c. Increases formation of purines. d. Increases metabolism of purines.

B

After the nurse has finished teaching a patient with osteoarthritis (OA) of the left hip and knee about how to manage the OA, which patient statement indicates a need for more education? a. I can take glucosamine to help decrease my knee pain. b. I will take 1 g of acetaminophen (Tylenol) every 4 hours. c. I will take a shower in the morning to help relieve stiffness. d. I can use a cane to decrease the pressure and pain in my hip.

B

The nurse reinforces medication teaching provided to a patient with rheumatoid arthritis. Which medication should the patient identify as helpful to control the symptoms of the health problem? a. Digoxin. b. Ibuprofen. c. Morphine. d. Penicillin.

B

When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to a. stand rather than sit when performing household chores. b. avoid activities that require continuous use of the same muscles. c. strengthen small hand muscles by wringing sponges or washcloths. d. protect the knee joints by sleeping with a small pillow under the knees.

B

Which information will the nurse include when teaching range-of-motion exercises to a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Application of cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

B

A patient has systemic sclerosis manifested by CREST (calcinosis, Raynauds phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep patients room warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

B. Keeping the room warm will decrease the incidence of Raynauds phenomenon, one aspect of the CREST syndrome.

After obtaining the health history from a 28-year-old woman who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information about the patient is most important for the nurse to report to the health care provider? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to have a baby before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

B. Methotrexate is teratogenic.

The health care provider has prescribed the following collaborative interventions for a 49-year-old who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Use naproxen (Aleve) 200 mg BID. d. Take famotidine (Pepcid) 20 mg daily.

B. No live viruses.

The nurse obtains this information when assessing a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis. Which symptom is most important to report to the health care provider? a. Abdominal cramping b. Complaint of blurry vision c. Phalangeal joint tenderness d. Blood pressure 170/84 mm Hg

B. Plaquenil can cause retinopathy; the medication should be stopped.

When caring for a patient with a new diagnosis of rheumatoid arthritis, which action will the nurse include in the plan of care? a. Instruct the patient to purchase a soft mattress. b. Teach patient to use lukewarm water when bathing. c. Suggest that the patient take a nap in the afternoon. d. Suggest exercise with light weights several times daily.

C

Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. Which laboratory result will the nurse monitor to determine whether the medication has been effective? a. Blood glucose test b. Liver function tests c. C-reactive protein level d. Serum electrolyte levels

C. C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective.

When caring for a patient who has osteoarthritis, the nurse will anticipate the need to teach the patient about which of these medications? a. Adalimumab (Humira) b. Prednisone (Deltasone) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

C. Capsaicin cream blocks the transmission of pain impulses. The other medications would be used for patients with RA.

A patient with rheumatoid arthritis refuses to take the prescribed methotrexate (Rheumatrex), telling the nurse That drug has too many side effects. My arthritis isnt that bad yet. The most appropriate response by the nurse is a. You have the right to refuse to take the methotrexate. b. Methotrexate is less expensive than some of the newer drugs. c. It is important to start methotrexate early to decrease the extent of joint damage. d. Methotrexate is effective and has fewer side effects than some of the other drugs.

C. Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA

A home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes. Which action by the nurse is most appropriate? a. Reassure the patient that dry eyes are a common problem with RA. b. Teach the patient more about adverse affects of the RA medications. c. Suggest that the patient start using over-the-counter (OTC) artificial tears. d. Ask the health care provider about lowering the methotrexate (Rheumatrex) dose.

C. dry eyes are consistent with Sjgrens syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended.

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

D. Diuretic use increases uric acid levels and can precipitate gout attacks.

The nurse is evaluating teaching provided to a patient with gout. Which patient menu selection indicates that additional teaching is required? a. Pike b. Bass c. Perch d. Sardines

D. The patient should avoid high-purine (protein) foods, such as organ meats, shellfish, and oily fish (e.g., sardines

The patient presents with contracture deformities of the hand and complains of severe pain. What musculoskeletal disorder does this patient manifest? 1. Rheumatoid arthritis 2. Osteomyelitis 3. Osteoporosis 4. Ankylosing spondylitis

1

When assessing a client diagnosed with ankylosing spondylitis, which of the following clinical manifestations will the nurse most likely assess? 1. Small irregular pupil 2. Heel pain 3. Onycholysis 4. Respiratory depression

1

Diagnostic procedures are being performed on a female patient who may have systemic lupus erythematosus (SLE). Which findings would the nurse evaluate as supporting this diagnosis? (SATA) 1. Elevated LE prep 2. Hematuria 3. Negative anti-SM antibody 4. C3 complement protein of 94 mg/dL 5. Sodium 138

1, 2

After teaching a patient diagnosed with progressive systemic sclerosis about health maintenance activities, the nurse determines that additional instruction is needed when the patient says, a. I should lie down for an hour after meals. b. Paraffin baths can be used to help my hands. c. Lotions will help if I rub them in for a long time. d. I should perform range-of-motion exercises daily.

A. Because of the esophageal scarring, patients should sit up for 2 hours after eating.

The nurse is reinforcing teaching provided to a patient with rheumatoid arthritis (RA). Which patient statement indicates understanding of the symptoms of RA? a. Fatigue b. Paralysis c. Crepitation d. Shortness of breath

A. Because of the systemic nature of RA, in addition to pain and joint involvement, the patient may have a low-grade fever, malaise, depression, lymphadenopathy, weakness, fatigue, anorexia, and weight loss.

The nurse is caring for a patient with gout. Which laboratory value should the nurse review which indicates that the treatment plan is effective? a. Uric acid: 7.9 mg/dL b. Creatinine: 0.8 mg/dL c. Blood urea nitrogen: 15 mg/dL d. Low-density lipoprotein (LDL): 115 mg/dL

A. The diagnosis of gout is based on an elevated serum uric acid level which is a waste product resulting from the breakdown of proteins

The nurse is reinforcing teaching provided to a patient with gout. Which food should the patient state will be avoided that indicates teaching has been effective? a. Rice b. Beets c. Liver d. Bananas

C

A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, I hate the way I look! I never go anywhere except here to the health clinic. An appropriate nursing diagnosis for the patient is a. activity intolerance related to fatigue and inactivity. b. impaired social interaction related to lack of social skills. c. impaired skin integrity related to itching and skin sloughing. d. social isolation related to embarrassment about the effects of SLE.

D

A patient with an acute attack of gout in the left great toe has a new prescription for probenecid (Benemid). Which information about the patients home routine indicates a need for teaching regarding gout management? a. The patient sleeps about 8 to 10 hours every night. b. The patient usually eats beef once or twice a week. c. The patient generally drinks about 3 quarts of juice and water daily. d. The patient takes one aspirin a day prophylactically to prevent angina.

D. Aspirin interferes with effectiveness of probenecid.

uveitis manifests as

edema of the upper eyelid

Other problems that occur with ankylosing spondylitis include

uveitis excessive lacrimation swollen iris