Chapter 39
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. Thyroid dysfunction, esophageal varices, and osteopenia are not associated with scleroderma.)
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 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. The diseases are not distinguished by the joints affected and neither has an infectious etiology.)
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'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 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 (Feedback: Tinnitus is associated with salicylate therapy. Salicylates do not normally cause drowsiness, intolerance of high-fat meals, or anorexia.)
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 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 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.)
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 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 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. Allopurinol is used to treat gout. Opioids are not indicated in early RA. Prednisone is used in unremitting RA.)
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 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. The muscle weakness is a product of the disease process, not lack of exercise. Skeletal muscle relaxants are not used in the treatment of polymyositis.)
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. OA, RA, and gout lack this dimension.)
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 (Feedback: Antimalarials may cause visual changes; regular ophthalmologic examinations are necessary.Tinnitus is associated with salicylate therapy, stomatitis is associated with gold therapy, and 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 (Feedback: Assessment of systemic involvement with scleroderma requires a systems review with special attention to gastrointestinal, pulmonary, renal, and cardiac systems. Liver, GU, and neurologic functions are not central priorities.)
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 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 (Feedback: Stomatitis is an adverse effect that is associated with gold therapy. Steroids, antimalarials, and salicylates do not normally have this adverse effect.)
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 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 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. There should be no need to change medications, and storing open medication containers is unsafe. Delegating medications to a family member is likely unnecessary at this point and promotes dependence.)
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 (Feedback: 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 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 (Feedback: Assessment in the patient's home setting can often reveal more meaningful data than an assessment in the health care setting. There is no indication that assisted living is a pressing need or that the patient would benefit from social work or a support group.)
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 (Feedback: 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. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. As well, these drugs should not be independently adjusted by the patient.)
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 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 (Feedback: 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. This finding is not characteristic of pneumonia and does not constitute S3. Posterior auscultation is unlikely to yield additional meaningful data.)
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 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 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 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 (Feedback: 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). There is not a particular clinical focus on the potential for bleeding, hand and foot pain, or thoracic pain.)
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 (Feedback: Corticosteroids are used for shortest duration and at lowest dose possible to minimize adverse effects. Daily blood work is not necessary and the patient does not need to stop other drugs prior to using corticosteroids.)
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 (Feedback: 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 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.)
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 (Feedback: 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. This progression of symptoms is inconsistent with GCA, FM, or RA.)
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 (Feedback: 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. VTE, OP, and degenerative joint disease are not among the most common complications for GCA.)
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 (Feedback: 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.)