Chapter 44: Disorders of the Skeletal System: Metabolic and Rheumatic Disorders-Patho http://thepoint.lww.com/Book/Show LEVEL 3

A patient has been diagnosed with rheumatoid arthritis (RA). Which of the following will the nurse tell the patient about this disorder's etiology? a) "Genetic predisposition is very likely." b) "The disease is most common in those under 30." c) "Environment is the biggest contributing factor to the development of RA." d) "Exposure to workplace chemicals is a causative agent."

"Genetic predisposition is very likely." The cause of RA is uncertain but evidence points to genetic predisposition. The disease usually occurs later in life.

A 64 year-old man was diagnosed 19 months ago with bilateral osteoarthritis (OA) in his knees, and has come to his family physician for a checkup. The client and his physician are discussing the affects of his health problem and the measures that the man has taken to accommodate and treat his OA in his daily routines. Which of the following statements by the client would necessitate further teaching? a) "I've been avoiding painkillers because I know they can mask damage that I might be inflicting on my knees." b) "Even though I don't like it, I've been using my walker to take some of the weight off my knees." c) "I'm really trying to lose weight and I've been able to lose 15 pounds this year so far." d) "I've been doing muscle strengthening exercises twice a week at the community center near my house."

"I've been avoiding painkillers because I know they can mask damage that I might be inflicting on my knees." Analgesics are a common and appropriate treatment for OA, and it would be unnecessary and inappropriate to forego pain control in order to maximize pain signals from affected joints. Weight loss, the use of assistive devices and muscle-strengthening exercises are appropriate treatments for OA.

A nurse is teaching a group of nursing students about the presentation of systemic lupus erythematosus (SLE). Which of the following statements does the nurse is likely to make? a) "Drug-induced lupus requires lifelong treatment." b) "Lupus is a disease of older individuals." c) "More women than men are affected by lupus." d) "Lupus is more common in Caucasians."

"More women than men are affected by lupus." There is a female predominance of 10:1 in those with SLE. This ratio is closer to 30:1 during childbearing years. -SLE is more common in African Americans, Hispanics, and Asians than in whites, and the incidence in some families is higher than in others

The nurse has just finished teaching a client newly diagnosed with rheumatoid arthritis about the disease. The nurse determines that teaching is effective when the client states: a) "The disease will not fluctuate in occurrence." b) "Rheumatoid arthritis includes joint involvement that is usually symmetric and polyarticular." c) "Only upper extremity diarthrodial joint can be involved." d) "Rheumatoid arthritis is a chronic autoimmune system disease that affects a single joint."

"Rheumatoid arthritis includes joint involvement that is usually symmetric and polyarticular." Joint involvement with rheumatoid arthritis usually is symmetric and polyarticular. Any diarthrodial joint can be involved. -The disease is characterized by exacerbations and remissions, may involve only a few joints for brief durations, or may become relentlessly progressive and debilitating.

Question: Joint destruction in rheumatoid arthritis occurs by an obscure process. The cellular changes, however, have been documented. Place the process in the correct order. 1 Immune complexes phagocytized, releasing lysosomal enzymes 2 Neutrophils, macrophages, and lymphocytes arrive 3 Vasodilation and joint swelling 4 Inflammatory response 5 Reactive hyperplasia of synovial cells and subsynovial tissues 6 Destructive changes in joint cartilage

1) Neutrophils, macrophages, and lymphocytes arrive 2) Immune complexes phagocytized, releasing lysosomal enzymes 3) Destructive changes in joint cartilage 4) Inflammatory response 5) Reactive hyperplasia of synovial cells and subsynovial tissues 6) Vasodilation and joint swelling The role of the autoimmune process in the joint destruction of RA remains obscure. At the cellular level, neutrophils, macrophages, and lymphocytes are attracted to the area. The neutrophils and macrophages phagocytize the immune complexes and, in the process, release lysosomal enzymes capable of causing destructive changes in the joint cartilage. The inflammatory response that follows attracts additional inflammatory cells, setting into motion a chain of events that perpetuates the condition. As the inflammatory process progresses, the synovial cells and subsynovial tissues undergo reactive hyperplasia. Vasodilation and increased blood flow cause warmth and redness. The joint swelling that occurs is the result of the increased capillary permeability that accompanies the inflammatory process.

When a nurse is administering medications to a patient with rheumatoid arthritis (RA), which of the following medications interferes with tumor necrosis factor (TNF)-alpha? a) Hydroxychloroquine b) Adalimumab c) Aspirin d) Methotrexate

Adalimumab Anti-TNF drugs such as infliximab, etanercept, and adalimumab are biologic response-modifying agents or TNF inhibitors that block TNF-alpha, one of the key proinflammatory cytokines in RA.

Adult rickets can result from several disorders. It can also have a pharmacologic basis for its onset. Which medication can cause rickets in an adult? a) Aluminum-sparing antacids b) Sulfur-based antibiotics c) Cephalosporins e) Sodium-sparing diuretics (THE QUESTION INCLUDED THE ANSWER DESCRIPTION)

Aluminum-sparing antacids As with osteomalacia in the adult, rickets can result from kidney failure; malabsorptive syndromes, such as celiac disease and cystic fibrosis; and medications, such as anticonvulsants, which cause target organ resistance to vitamin D, and aluminum-containing antacids, which bind phosphorous and prevent its absorption. - The other drugs are not used to treat rickets.

When teaching a patient with rheumatoid arthritis (RA), which of the following factors does the nurse explain is an underlying cause of this disease? a) Tissue necrosis b) Immunocompromised host c) Autologous antibodies d) Lysosomes

Autologous antibodies The pathogenesis of RA can be viewed as an aberrant immune response that leads to synovial inflammation and destruction of the joint architecture. Approximately 70-80% of people with the disease have a substance called rheumatoid factor, which is an autologous (self-produced) antibody that causes joint destruction.

Juvenile dermatomyositis is a chronic inflammatory myopathy that commonly manifests systemically. What is the treatment of choice for this myopathy? a) Muscle relaxants b) Corticosteroids c) Nonsteroidal anti-inflammatory drugs (NSAIDs) d) IgG

Corticosteroids Corticosteroids are the mainstay of treatment for these conditions. -The other drug types are not the treatment of choice for polymyositis and dermatomyositis.

Osteoporosis is a disease caused by demineralization of bone. What is the clinical method of choice for diagnosing osteoporosis? a) Serum calcium levels b) Magnetic resonance imaging (MRI) of the chest cavity and femur c) Body mass index (BMI) d) Dual-energy x-ray absorptiometry (DXA or DEXA) of the spine and hip

Dual-energy x-ray absorptiometry (DXA or DEXA) of the spine and hip The clinical method of choice for bone mineral density (BMD) studies is dual-energy x-ray absorptiometry (DXA or DEXA) of the spine and hip. The other answers will not diagnose osteoporosis.

Which diagnostic finding has been strongly linked to systematic lupus erythematosus (SLE)? a) Elevated anti-nuclear antibodies (ANA) b) Decreased rheumatoid factor c) Low red blood cell count d) An abnormal serum SLE assay

Elevated anti-nuclear antibodies (ANA) While there is no laboratory finding that will provide a definite diagnosis of SLE, the ANA is elevated in 95% of untreated SLE.

Which statement is true regarding the development of juvenile idiopathic arthritis? a) Generalized stunted growth can occur. b) The condition will resolve in adulthood. c) A diagnosis will be made when two joints are affected. d) Surgical intervention can stop the decline associated with the arthritis.

Generalized stunted growth can occur. Generalized stunted growth can occur as well as unilateral increased growth related to the influence on epiphyseal growth. It will not resolve in adulthood, and surgical intervention is not an option to eliminate the disease.

A nurse is caring for a patient undergoing antineoplastic chemotherapy for acute leukemia. Which of these diagnostic studies does the nurse monitor to detect the consequences of the rapid lysis of cancer cells? a) Antinuclear antibody b) Hypokalemia c) Hyperuricemia d) Hypophosphatemia

Hyperuricemia In secondary gout, hyperuricemia may be caused by the increased breakdown of nucleic acids, as occurs with rapid tumor cell lysis during treatment for lymphoma or leukemia.

A daughter is concerned because her elderly parent has been diagnosed with osteomalacia. The daughter asks the nurse why this happened. The best response would be that: a) Not using any sunscreens to help with absorption b) Absorption of too much vitamin D c) Consumption of a diet high in calcium d) Intestinal absorption slows as a natural aging process

Intestinal absorption slows as a natural aging process The incidence of osteomalacia is high among the elderly because of diets deficient in calcium and vitamin D, a problem often compounded by the intestinal malabsorption that accompanies with aging. -Melanin is extremely efficient in absorbing UVB radiation; thus, decreased skin pigmentation markedly reduces vitamin D synthesis, as does the use of sunscreens. -Osteomalacia also may occur in persons on long-term treatment with medications such as anticonvulsants (e.g., phenytoin, carbamazepine, valproate) that decrease the activation of vitamin D in the liver

Due to her progressing osteoarthritis (OA), an 80 year-old woman is no longer able to perform her activities of daily living without assistance. Which of the following phenomena most likely underlies the woman's situation?

Loss of articular cartilage and synovitis has resulted from inflammation caused when joint cartilage attempted to repair itself. The joint changes associated with osteoarthritis, which include a progressive loss of articular cartilage and synovitis, results from the inflammation caused when cartilage attempts to repair itself, creating osteophytes or spurs. These changes are accompanied by joint pain, stiffness, limitation of motion, and in some cases by joint instability and deformity. - Immune etiology is more associated with rheumatoid arthritis and -collagen deposits are characteristic of scleroderma. -Bones do not tend to fuse in the pathogenesis of OA.

The nurse is assessing a patient with ankylosing spondylitis (AS). Which of the following does the nurse expect to find? a) Joint contractures b) Facial butterfly rash c) Bruises on the lower extremities d) Lower back pain

Lower back pain The patient with AS has an inflammatory erosion of the sites where tendons and ligaments attach to bone. The disease progresses with bilateral involvement of the sacroiliac joints and produces lower back pain. -Joint contractures, butterfly rash, and bruises are not characteristic of this disease.

The nurse is conducting a health promotion class on osteoarthitis (OA). Which of the following statements should the nurse include? a) Eating a diet low in calcium is the only contributing risk factor to OA. b) Obesity is a strong risk factor for developing OA. c) There is no hereditary link to the development of OA. d) Young women have a higher risk than young men of developing OA.

Obesity is a strong risk factor for developing OA. Obesity is a strong risk factor for OA of the knee in women, and a contributory biomechanical factor in the pathogenesis of the disease. Young men have a higher risk, but after middle age women are more at risk for developing OA. -The statements regarding heredity and diet are not true.

Which of the following assessment findings best confirms the diagnosis of systemic lupus erythematosis (SLE)? a) Elevated antinuclear antibodies (ANA) levels b) Positive anti-DNA antibody test. c) Joint pain d) Facial rash

Positive anti-DNA antibody test. SLE has been termed the great imitator, as it presents with many different symptoms. Although joint pain, facial rash, and chest pain may occur, these symptoms also occur with other disorders. Elevated ANA levels occur in SLE; however, they are also elevated in other disorders. The ANA test is more specific for the diagnosis of SLE

A young adult male client presents to the orthopedic clinic complaining of "stiffening of the spine." The health care provider orders some diagnostic lab work. Which lab result leads the health care worker to diagnose ankylosing spondylitis? a) Severe decrease in red blood cells associated with decreased iron levels b) Elevated serum calcium level of 15.1 mg/dL c) Presence of HLA-B27 allele marker d) Elevated serum uric acid level

Presence of HLA-B27 allele marker The HLA-B27 antigen remains one of the best-known examples of an association between a disease and a hereditary marker; approximately 90% of those with ankylosing spondylitis possess the HLA-B27 antigen. Primary gout is often caused by an inborn error in metabolism and is characterized primarily by hyperuricemia and gout. The person also may have a mild normocytic normochromic anemia but not iron deficiency anemia.

The nurse caring for a child with a deficiency of vitamin D knows that the deficiency places the child at risk for which of the following?

Rickets Rickets is associated with a Vitamin D deficiency while -scurvy is associated with a Vitamin C deficiency. - Hip dysplasia is not associated with a Vitamin D deficiency. -Paget disease is not associated with children.

When comparing a child's clinical manifestations with that of oligoarthritis versus systemic onset, the health care provider diagnoses this in your 4-year-old child with oligoarthritis based on which of the following clinical findings?

Right knee is warm and painful when putting it through normal range of motion. Oligoarthritis, which is the most common type of JIA (juvenile idiopathic arthritis) predominantly affects joints of the lower extremities, usually the knees or ankle. -Involvement of upper extremity large joints and the hip is rarely a presenting sign. -Often a single joint is affected at onset. Children with this form of JIA are usually younger (1 to 5 years at onset) and are often rheumatoid factor (RF) positive. The symptoms of systemic JIA include a daily intermittent high fever, which usually is accompanied by a characteristic faint, erythematous, macular rash. The rash is not pruritic.

A client is experiencing an episode of gout. The nurse recognizes that the condition is a result of: a) Serum uric acid levels b) Serum calcium levels c) Serum calcitonin levels d) Serum blood urea nitrogen (BUN)

Serum uric acid levels Gout resides in an elevation of serum uric acid levels. The elevation of uric acid and the subsequent development of gout can result from overproduction of purines, decreased salvage of free purine bases, augmented breakdown of nucleic acids as a result of increased cell turnover, or decreased urinary excretion of uric acid. - The other lab values would not contribute to gout.

While reviewing the following diagnostic findings on a group of patients with joint complaints, which finding would be a priority for further investigation and possible medical intervention? a) A 55 year-old male reveals that it takes a day or two for oral colchicines to relive his attacks of gout. b) A male client has elevated levels of serum uric acid but lacks symptoms. c) Synovial fluid aspiration indicates the presence of monosodium urate crystals. d) A man reveals that he eats organ meat 2 to 3 times weekly.

Synovial fluid aspiration indicates the presence of monosodium urate crystals. The presence of crystalline deposits in synovial fluid confirms a diagnosis of gout and would necessitate further investigation and/or treatment. -Hyperuricemia is not necessarily indicative of gout, and -while diet can contribute to gout, this would not necessarily require modification in the absence of gout. -Oral colchicine often takes 48 hours to take effect during an acute attack of gout

A nurse is caring for a patient admitted with a malar rash on the nose and cheeks. The nurse recognizes that this rash is characteristic of which of the following disease processes?

Systemic lupus erythematosus The acute skin lesions include the classic malar or "butterfly" rash on the nose and cheeks.

The nurse is teaching a patient with rheumatoid arthritis about pannus, which develops in the affected joint area. Which of the following does the nurse include to describe pannus? a) Reversible calcium deposits affecting the joints b) Microorganisms that attack the joint space causing stiffness c) Vascular granulation tissue that destroys cartilage and bone d) Muscles in the area that atrophy from disuse

Vascular granulation tissue that destroys cartilage and bone A network of new blood vessels in the synovial membrane that contributes to the advancement of the rheumatoid synovitis, called pannus, develops. This destructive vascular granulation tissue extends from the synovium to involve a region of unprotected bone at the junction between cartilage and the subchondral bone. Inflammatory cells found in the pannus have a destructive effect on adjacent cartilage and bone leading to reduced joint motion and the possibility of eventual ankylosis (fusion of the bones causes abnormal stiffening and immobility of the joint).

A client presented to the emergency department after getting "hit in the head with a baseball" while watching his grandson play. An x-ray of the head reveals poor quality of bone. The ED physician suspects the client has Paget disease. Which of the following signs/symptoms helps confirm this diagnosis? Select all that apply. a) "I've had a lot of headaches lately." b) "Do you see my knuckles...they have big growths on them." c) "My thumb joint has been cracking every time I rotate it." d) "I have gotten dizzy and had to sit down while shopping." e) "Every now and then, I get a ringing in my ears."

• "I've had a lot of headaches lately." • "Every now and then, I get a ringing in my ears." • "I have gotten dizzy and had to sit down while shopping." Skeletal expansion and distortion may be obvious if the disease affects the skull, jaw, clavicle, or long bones of the leg. Involvement of the skull causes headaches, intermittent tinnitus (ringing in the ears), vertigo (dizziness), and eventual hearing loss. - The abnormal knuckles and thumb joint are related to arthritis.

When planning care for the client with severe osteoarthritis (OA) of the hip, the nurse includes which of the following in a teaching session with the patient? a) "Losing weight or maintaining your ideal weight reduces stress on your joints." b) "Try to balance your rest and exercise." c) "Using heat or cold to relieve pain may be helpful." d) "Avoid nonsteroidal anti-inflammatory medications." e) "A walker may be helpful to avoid excess pressure on your hips." (QUESTION DID NOT SAY SELECT ALL THAT APPLY but allowed for multiple selections)

• "Try to balance your rest and exercise." • "Using heat or cold to relieve pain may be helpful." • "Losing weight or maintaining your ideal weight reduces stress on your joints." • "A walker may be helpful to avoid excess pressure on your hips." Treatment of OA focuses on symptom relief: a balance of rest and exercise, use of splints to protect and rest the joint, use of heat and cold to relieve pain and muscle spasms, and adjusting the activities of daily living. Weight reduction is helpful (when weight-bearing surfaces are involved), and the use of a cane or walker if the hips and knees are involved is recommended.

When assessing a patient diagnosed with Paget disease focused in the skull, the nurse should anticipate which of the following findings? a) Intermitent tinnitus b) Visual disturbances c) Headaches d) Vertigo e) Hearing loss

• Headaches • Intermittent tinnitus • Vertigo • Hearing loss Involvement of the skull can cause headaches, intermittent tinnitus, vertigo, and eventual hearing loss. - Visual impairment is not associated with Paget disease of the skull.

A patient recently diagnosed with rheumatoid arthritis (RA) tells the nurse she is glad there is nothing "really wrong with her" but some joint swelling. Which of the following information should the nurse tell the patient about RA?

"Extra-articular manifestations may include anemia and deformities of the affected joints." Although characteristically a joint disease, RA can affect a number of other tissues including red blood cells, blood vessels, lungs, and heart. Treatment goals for a person with RA are to prevent and/or reduce the pain, decrease stiffness and swelling, maximize mobility, and possibly halt the progression, but not cure the disease.

A nurse is caring for a patient with a fractured elbow. Which of the following instructions is important to give the patient to prevent cartilage degeneration while the elbow is immobilized?

"To prevent cartilage atrophy, slowly and gradually resume exercising." Cartilage atrophy is rapidly reversible with activity after a period of immobilization; -impact exercise during the period of remobilization can prevent reversal of the atrophy. -Slow and gradual remobilization may be important in preventing cartilage injury.

The nurse determines that additional patient education is needed when a patient with gout makes which one of the following statements? a) "When I have an exacerbation of my symptoms, a glass of red wine will be helpful." b) "I will plan to eat more white meat rather than red meat." c) "I should avoid eating shellfish to decrease the risk of an episode." d) "Increasing my intake of water each day will help stop the symptoms."

"When I have an exacerbation of my symptoms, a glass of red wine will be helpful." The statement about drinking alcohol to decrease the symptoms would need more follow-up, since it is a strong contributor to an exacerbation of gout. -The other statements are valid.

A client with confirmed low bone density asks the nurse if there is anything she can do to decrease the risk of trauma. The best response would be:

Brisk walking three times per week on a flat surface Weight-bearing exercises such as walking, jogging, rowing, and weight lifting are important in the maintenance of bone mass. -The other options place the person at risk for injury if the bones are weakened.

A female athlete has been diagnosed with amenorrhea due to intense training for a spot on the Olympic swimming team. As a health care provider, which of the following should be implemented to prevent premature osteoporosis?

Calcium/vitamin D supplements to support BMD. The female athlete triad, a pattern of disordered eating that leads to amenorrhea and eventually premature osteoporosis, is being seen increasingly in female athletes because of an increased prevalence of eating disorders. Poor nutrition, combined with intense exercise training, can lead to decrease in the critical body fat-to-muscle ratio needed for normal menses and estrogen production by the ovary. The lack of estrogen combined with the lack of calcium and vitamin D from dietary deficiencies results in a loss of bone density and increased risk of fractures. -Older athletes are at high risk for osteoarthritis, a degenerative joint disorder that is unrelated loss of bone density.

The client with a suspected diagnosis of osteoarthritis asks the health care provider how the diagnosis will be confirmed. The best response would be: a) Exercise trials b) Biopsy c) History and physical examination, x-ray studies, and laboratory findings that exclude other diseases d) Bone marrow aspiration

History and physical examination, x-ray studies, and laboratory findings that exclude other diseases The diagnosis of OA usually is determined by history and physical examination, x-ray studies, and laboratory findings that exclude other diseases. - The other options would not identify the disease.

A patient with ankylosing spondylitis wants to begin an exercise program. Which of the following does the nurse recommend? a) Bowling b) Jogging c) Golfing d) Swimming

Swimming Muscle-strengthening exercises for extensor muscle groups are prescribed. Swimming is an excellent general conditioning exercise that avoids joint stress and enhances muscle tone.

Select the statement that best describes systemic lupus erythematosus (SLE). SLE is characterized by which of the following?

The formation of autoantibodies and immune complexes (type III hypersensitivity) SLE is characterized by the formation of autoantibodies and immune complexes (type III hypersensitivity; - T-cell-mediated response to an immunologic trigger occurs in RA). SLE may be acute or insidious, and the course of the disease is characterized by exacerbations and remissions. -Exposure to UV light, specifically UVB associated with exposure to the sun or unshielded fluorescent bulbs, may trigger exacerbations.

A client presents to the orthopedic clinic for evaluation since the primary care provider thinks the client may have rheumatoid arthritis (RA). Which statement by the client correlates with the diagnosis of RA? Select all that apply. a) "Look how my hand is deformed. My doctor calls it 'hyperextension.'" b) "Every time I get something out of the freezer, my hands turn reddish purple in color." c) "I'm having a hard time opening doors since it hurts so bad." d) "Just look at my face. It looks like I have varicose veins on my cheeks." e) "Look, I didn't button all my shirt buttons...it just hurts too much and look at the swelling in my hands."

• "I'm having a hard time opening doors since it hurts so bad." • "Look, I didn't button all my shirt buttons...it just hurts too much and look at the swelling in my hands." • "Look how my hand is deformed. My doctor calls it 'hyperextension.'" Rheumatoid arthritis (RA) joint involvement usually is symmetric and polyarticular. Pain with turning door knobs, opening jars, and buttoning shirts is commonly reported due to swelling of the wrists and small joints of the hand. Hyperextension of the PIP joint and partial flexion of the distal interphalangeal (DIP) joint is called a swan neck deformity. As the RA inflammatory process progresses, synovial cells and subsynovial tissues undergo reactive hyperplasia. With osteoarthritis (OA), joint changes result from the inflammation caused when the cartilage attempts to repair itself, creating osteophytes or spurs. -Raynaud phenomenon (a vascular disorder characterized by reversible vasospasm of the arteries supplying the fingers) and telangiectasia (dilated skin capillaries) are characteristic of scleroderma.

When teaching a patient about areas of the body typically affected by gout, the nurse should include which of the following areas? Select all that apply. a) Metatarsals b) Instep c) Hip d) Heel e) Heart

• Metatarsals • Instep • Heel The typical acute attack of gout is monoarticular and usually affects the first metatarsophalangeal joint. The tarsal joints, insteps, ankles, heels, knees, wrists, fingers, and elbows also may be initial sites of involvement.

Scleroderma is an autoimmune disease of connective tissue that is characterized by hardening of the skin. What diseases do almost all people with scleroderma develop? (Select all that apply.)

• Polyarthritis • Raynaud phenomenon Almost all persons with scleroderma develop polyarthritis and Raynaud phenomenon, a vascular disorder characterized by reversible vasospasm of the arteries supplying the fingers. -Dumping syndrome, chronic diarrhea, and chronic vasoconstriction are not diseases developed by people with scleroderma.

Which of the following are potential causes of osteoarthritis? (Select all that apply.) a) Cardiovascular disease b) Collagen disorders c) Rheumatoid arthritis d) Metabolic disorders e) Postraumatic disorders

• Rheumatoid arthritis • Postraumatic disorders • Metabolic disorders • Collagen disorders Rheumatoid arthritis, posttraumatic disorders, metabolic disorders and collagen disorders are all possible causes of osteoarthritis.