Chapter 39: Rheumatic Disorders

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

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

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included? a) Exercising immediately upon awakening allows the client to participate in activities when he has the greatest amount of energy. b) Exercising at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided. c) Exercising in the evening before going to bed is beneficial. d) The time of day when exercise is performed isn't important.

b) Exercising at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided. A client with osteoarthritis has increased stiffness in the morning upon awakening. Exercise should be scheduled at least 1 hour after awakening. Exercising in the evening interferes with the client's ability to rest at bedtime.

When developing a care plan for a client newly diagnosed with scleroderma, which nursing diagnosis has the highest priority? a) Impaired gas exchange b) Impaired skin integrity c) Imbalanced nutrition: More than body requirements d) Risk for constipation

b) Impaired skin integrity Impaired skin integrity is a concern for the client with scleroderma in its earlier stages. Meticulous skin care is required to prevent complications. Although Risk for constipation may also be appropriate, this nursing diagnosis isn't the priority. Clients with scleroderma are at risk for Imbalanced nutrition: Less than body requirements. The client with advanced scleroderma, not newly diagnosed scleroderma, is at increased risk for developing respiratory complications.

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

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

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

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

A client with osteoarthritis tells the nurse she is concerned that the disease will prevent her from doing her chores. Which suggestion should the nurse offer? a) "Do all your chores in the morning, when pain and stiffness are least pronounced." b) "Do all your chores in the evening, when pain and stiffness are least pronounced." c) "Pace yourself and rest frequently, especially after activities." d) "Do all your chores after performing morning exercises to loosen up."

c) "Pace yourself and rest frequently, especially after activities." A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace herself during daily activities. Telling the client to do her chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace herself and take frequent rests rather than doing all chores at once.

A client with gout has been advised to lose weight. She informs the nurse that she plans to go on a "guaranteed rapid weight loss" plan that involves fasting and heavy exercise. Which response would be most appropriate? a) "Try combining the fasting with moderate exercise." b) "The fasting is okay, but make sure you drink fluids when exercising." c) "There might be some difficulties with your plan and fasting." d) "Make sure to eat some fat occasionally with all that exercise."

c) "There might be some difficulties with your plan and fasting." Clients should avoid fasting, low-carbohydrate diets, and rapid weight loss because these measures increase the likelihood of ketone formation, which inhibits uric acid excretion. Gradual weight loss helps reduce serum uric acid levels in clients with gout.

The nurse is caring for a patient who has been diagnosed with "rheumatic disease." What nursing diagnoses will most likely apply to this patient's care? Select all that apply a) Fatigue b) Alteration in self-concept c) Fluid and electrolyte imbalance d) Pain e) Fluid volume deficit

a) Fatigue b) Alteration in self-concept d) Pain Patients with rheumatic diseases, which typically involve joints and muscles, cause problems with mobility, fatigue, and pain. Due to limitations of the disease, the patients often have an altered self-image and self-concept. Fluid and electrolyte imbalances are not typically associated with these types of diseases.

A client with degenerative joint disease asks the nurse for suggestions to avoid unusual stress on the joints. Which suggestion would be most appropriate? a) Maintain complete bed rest. b) Keep shifting weight from one foot to the other. c) Perform aerobic exercises. d) Maintain good posture.

d) Maintain good posture. The nurse needs to remind the client with degenerative joint disease to maintain good posture. While the client need not maintain complete bed rest, performing aerobic exercises is not advisable as it may place undue stress on the joint worsening the condition. Shifting weight from one foot to the other does not help avoid unusual stress on a joint.

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

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

What intervention is a priority for a patient diagnosed with osteoarthritis? a) Physical therapy and exercise b) Colchicine c) Allopurinol (Zyloprim) d) Hydrotherapy

a) Physical therapy and exercise Patients with osteoarthritis need to maintain joint mobility. To preserve joint function, individuals need to learn appropriate activities. Colchicine and Zyloprim are used for gout, not osteoarthritis. Hydrotherapy is not a priority for care.

Which of the following would the nurse expect to assess as the most common finding associated with fibromyalgia? a) Heberden nodes b) Butterfly facial rash c) Jaw locking d) Widespread chronic pain

d) Widespread chronic pain The most common finding associated with fibromyalgia is widespread and chronic pain. Heberden nodes are associated with osteoarthritis. Jaw locking is a manifestation of temporomandibular joint dislocation. A butterfly facial rash is associated with systemic lupus erythematosus.

Which of the following connective tissue disorders is characterized by insoluble collagen being formed and accumulating excessively in the tissues? a) Scleroderma b) Systemic lupus erythematosus c) Polymyalgia rheumatic d) Rheumatoid arthritis

a) Scleroderma Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue with damage taking place in body joints. SLE is an immunoregulatory disturbance that results in increased autoantibody production. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

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

a) Shows a weight gain of 2 pounds Fatigue is common with rheumatoid arthritis. Finding a balance between activity and rest is an essential part of the therapeutic regimen.

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

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

Which of the following is the most common joint affected in gout? a) Tarsal area b) Metatarsophalangeal c) Knee d) Ankle

b) Metatarsophalangeal The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of patients), and this is referred to as podagra. Less commonly, the wrists, fingers, and elbows may be affected. The tarsal area, ankle, and knee are not the most commonly affected in gout.

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

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

Which of the following is an appropriate nursing intervention in the care of the patient with osteoarthritis? a) Provide an analgesic after exercise b) Avoid the use of topical analgesics c) Encourage weight loss and an increase in aerobic activity d) Assess for the gastrointestinal complications associated with COX-2 inhibitors

c) Encourage weight loss and an increase in aerobic activity Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening are important approaches to pain management. Patients should be assisted to plan their daily exercise at a time when the pain is least severe, or plan to use an analgesic, if appropriate, prior to their exercise session. Gastrointestinal complications, especially GI bleeding, are associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Topical analgesics such as capsaicin and methylsalicylate may be used for pain management.

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

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

A nursing student asks the instructor how to identify rheumatoid nodules in a client with rheumatoid arthritis. Which of the following characteristics would the instructor include? a) Reddened b) Nonmovable c) Located over bony prominence d) Tender to touch

c) Located over bony prominence Rheumatoid nodules usually are nontender, movable, and evident over bony prominences, such as the elbow or the base of the spine. They are not reddened.

Which findings best correlate with a diagnosis of osteoarthritis? a) Erythema and edema over the affected joint b) Anorexia and weight loss c) Fever and malaise d) Joint stiffness that decreases with activity

d) Joint stiffness that decreases with activity A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that decreases with activity and movement. Erythema and edema over the affected joint, anorexia, weight loss, and fever and malaise are associated with rheumatoid arthritis, a more severe and destructive form of arthritis.

Which of the following is an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage? a) Joint effusion b) Subchondral bone c) Pannus d) Tophi

d) Tophi Tophi, when problematic, are surgically excised. Subchondral bone refers to a bony plate that supports the articular cartilage. Pannus refers to newly formed synovial tissue infiltrated with inflammatory cells. Joint effusion refers to the escape of fluid from the blood vessels or lymphatic vessels into the joint cavity.

Which of the following disorders is characterized by an increased autoantibody production? a) Scleroderma b) Rheumatoid arthritis (RA) c) Systemic lupus erythematosus (SLE) d) Polymyalgia rheumatic

c) Systemic lupus erythematosus (SLE) SLE is an immunoregulatory disturbance that results in increased autoantibody production. Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

A patient is taking NSAIDs for the treatment of osteoarthritis. What education should the nurse give the patient about the medication? a) Inform the physician if there is ringing in the ears. b) Since the medication is able to be obtained over the counter, it has few side effects. c) Take the medication with food to avoid stomach upset. d) Take the medication on an empty stomach in order to increase effectiveness.

c) Take the medication with food to avoid stomach upset. The nurse should advise the patient to take NSAIDs with food to avoid stomach upset.

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

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

A nurse is assessing a client with possible osteoarthritis. The most significant risk factor for primary osteoarthritis is: a) congenital deformity. b) trauma. c) age. d) obesity.

c) age. Age is the most significant risk factor for developing primary osteoarthritis. Development of primary osteoarthritis is influenced by genetic, metabolic, mechanical, and chemical factors. Secondary osteoarthritis usually has identifiable precipitating events such as trauma.

Diagnosis of osteoarthritis is complicated because initial joint changes occur without symptoms. Therefore, a combination of physical assessment and X-ray review is necessary for a diagnosis. Select two signs that, when combined, are sensitive indicators of OA. a) Tender joints b) Joint pain c) Enlarged joints d) Joint space narrowing e) Osteophytes

d) Joint space narrowing e) Osteophytes Standard X-rays of affected joints show osteophytes, the most characteristic feature of OA, and in more advanced disease, joint space narrowing and sclerosis. When these two are combined, a diagnosis of OA is established.

Ms. Dowe was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. Which of the following would not be a part of teaching plan for her condition? a) Regular exercise and stress reduction b) Encouraging the client to eat a healthy diet c) Applications of ice d) Avoiding caffeine and alcohol

c) Applications of ice Application of ice is not part of the treatment regimen. Encouraging the client to eat a healthy diet, avoiding caffeine and alcohol, regular exercise, and stress reduction are part of the teaching plan.

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

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