🟧 Chapter 64 - Arthritis and Connective Tissue Diseases

7. Teach the patient with fibromyalgia the importance of limiting intake of which foods? (select all that apply) a. Sugar b. Alcohol c. Caffeine d. Red meat e. Root vegetables

A,B,C Rationale: Dietitians often urge patients with fibromyalgia to limit their intake of sugar, caffeine, and alcohol because these substances have been shown to be muscle irritants

1. In assessing the joints of a patient with osteoarthritis, the nurse understands that Bouchard's nodes a. are often red, swollen, and tender. b. indicate osteophyte formation at the PIP joints. c. are the result of pannus formation at the DIP joints. d. occur from deterioration of cartilage by proteolytic enzymes.

B Rationale: Bouchard's nodes are bony deformities of the proximal interphalangeal joints that indicate osteophyte formation and loss of joint space in osteoarthritis.

3. When administering medications to the patient with chronic gout, the nurse recognizes which drug is used as a treatment for this disease? a. Colchicine b. Allopurinol c. Sulfasalazine d. Cyclosporine

B Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for longterm management of hyperuricemia in persons with chronic gout. An acute episode of gout is treated with colchicine and NSAIDs

4. The nurse should teach the patient with ankylosing spondylitis the importance of a. avoiding extremes in environmental temperatures b. regularly exercising and maintaining proper posture. c. maintaining patient's usual physical activity during flares. d. applying hot and cool compresses for relief of local symptoms.

B Rationale: Patients with AS should exercise after pain and stiffness are managed. Teach the patient with AS about regular exercise and attention to posture, local moist-heat applications, and knowledgeable use of drugs. Postural control is important for minimizing spinal deformity. Proper positioning at rest is essential. Postural training emphasizes avoiding spinal flexion (e.g., leaning over a desk), heavy lifting, and prolonged walking, standing, or sitting. Exercise should include back, neck, and chest stretches. Discourage excessive physical exertion during periods of active flare-up of the disease. The mattress should be firm. The patient should sleep on the back with a flat pillow, avoiding positions that encourage flexion deformity

2. A patient with rheumatoid arthritis has articular involvement. The nurse recognizes these characteristic changes include (select all that apply) a. bamboo-shaped fingers. b. metatarsal head dislocation in feet. c. noninflammatory pain in large joints. d. asymmetric involvement of small joints. e. morning stiffness lasting 60 minutes or more.

B,E Rationale: Morning stiffness may last from 60 minutes to several hours or more, depending on disease activity. Metatarsal head dislocation and subluxation in the feet may cause pain and walking disability. Joint symptoms occur symmetrically and often affect the small joints of the hands (proximal interphalangeal [PIP] and metacarpophalangeal [MCP] joints) and feet (metatarsophalangeal [MTP] joints). Larger peripheral joints such as the wrists, elbows, shoulders, knees, hips, ankles, and jaw may be involved. Rheumatoid arthritis is an inflammatory disorder. In early disease, the fingers may become spindle-shaped from synovial hypertrophy and thickening of the joint capsule.

6. In teaching a patient with Sjögren's syndrome about drug therapy for this disorder, the nurse includes instruction about the use of which drug? a. Pregabalin (Lyrica) b. Etanercept (Enbrel) c. Cyclosporine (Restasis) d. Cyclobenzaprine (Flexeril)

C Rationale: Cyclosporine (Restasis) ophthalmic drops can be used to treat the chronic dry eye associated with Sjögren's syndrome.

A 66 year old man with type 2 diabetes and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask ? - did you have and hypoglycemic reactions? - have you noticed and bruising or bleeding - have you has any dizzy spells when standing ? do you have any numbness or tingling in our feet?

Correct Answer: "Have you noticed any bruising or bleeding?" Rationale: Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both may increase the risk of bleeding. Patients with atrial fibrillation routinely take an anticoagulant to reduce the risk of venous thromboembolism and stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose, and hyperglycemia may occur.

The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement? "I perform range of motion exercises at least twice a day." "I use a heating pad for 20 minutes to reduce morning stiffness." "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

Correct Answer: "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)." Rationale: Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

When reinforcing health teaching on managing osteoarthritis, which patient statement indicates additional instruction is needed? "I can use a cane to relieve the pressure on my back and hip." "I should take the Naprosyn as prescribed to help control the pain." "I should try to stay standing all day to keep my joints from becoming stiff." "A warm shower in the morning will help relieve the stiffness I have when I get up."

Correct Answer: "I should try to stay standing all day to keep my joints from becoming stiff." Rationale: Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.

The nurse is delivering teaching to a female patient newly diagnosed with systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? "I'll try my best to stay out of the sun this summer." "I know that I have a high chance of getting arthritis." "I'm hoping surgery will be an option for me in the future." "I understand I'm going to be vulnerable to getting infections."

Correct Answer: "I'm hoping surgery will be an option for me in the future." Rationale: Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.

A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? "Infertility can result from some medications used to control your disease." "Temporary remission of your signs and symptoms is common during pregnancy." "Autoantibodies transferred to the baby during pregnancy will cause heart defects." "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth."

Correct Answer: "Infertility can result from some medications used to control your disease." Rationale: Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common after pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.

Which statement suggests a need for the nurse to assess the patient for ankylosing spondylitis? "My right elbow has become red and swollen over the last few days." "I wake up stiff every morning, and my knees just don't want to bend." "My husband tells me that my posture has become so stooped this winter." "My lower back pain seems to be getting worse and nothing seems to help."

Correct Answer: "My lower back pain seems to be getting worse and nothing seems to help." Rationale: AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.

The patient developed acute gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout? Decrease fluid intake Drink a glass of wine daily Administration of probenecid Administration of allopurinol

Correct Answer: Administration of allopurinol Rationale: To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the patient's aspirin will inactivate its effect, resulting in urate retention. Dietary restrictions that limit alcohol and foods high in purine help minimize uric acid production.

A patient with longstanding Raynaud's phenomenon currently reports red spots on the hands, forearms, palms, face, and lips. Which additional findings would the nurse expect? (Select all that apply.) Calcinosis Weight loss Sclerodactyly Difficulty swallowing Weakened leg muscles Skin thickening below the elbow and knee

Correct Answer: Calcinosis Sclerodactyly Difficulty swallowing Skin thickening below the elbow and knee Rationale: This patient is at risk for scleroderma. The acronym CREST represents the manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud's phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.

The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites? The best therapy for the acute illness is IV antibiotics. Check for an enlarging reddened area with a clear center. Surveillance is necessary during the summer months only. Antibiotics will prevent Lyme disease if taken for 10 days.

Correct Answer: Check for an enlarging reddened area with a clear center. Rationale: After a tick bite, the expanding "bull's eye rash" is the most characteristic symptom that usually occurs in 3 to 30 days. Flu-like symptoms and migrating joint and muscle pain also may be present. Active lesions are treated with oral antibiotics for 2 to 3 weeks; doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. No vaccine is available.

A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan? Joint destruction caused by an autoimmune process Degeneration of articular cartilage in synovial joints Overproduction of synovial fluid resulting in joint destruction Breakdown of tissue in non-weight-bearing joints by enzymes

Correct Answer: Degeneration of articular cartilage in synovial joints Rationale: OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.

The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure should the nurse recommend to slow progression of the disease? Use a wheelchair to avoid walking as much as possible. Sit in chairs that cause the hips to be lower than the knees. Eat a well-balanced diet to maintain a healthy body weight. Use a walker for ambulation to relieve the pressure on the hips.

Correct Answer: Eat a well-balanced diet to maintain a healthy body weight. Rationale: Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.

The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient's choice of which food item indicates an understanding of the instructions? Eggs Liver Salmon Chicken

Correct Answer: Eggs Rationale: Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient's knees? Ulnar drift Pain with joint movement Reddened, swollen affected joints Stiffness that increases with movement

Correct Answer: Pain with joint movement Rationale: Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.

Four patients have been newly diagnosed with connective tissue disorders. The nurse is concerned with safety issues and interstitial lung involvement for the patient with which diagnosis? Polymyositis Reactive arthritis Sjögren's syndrome Systemic lupus erythematosus (SLE)

Correct Answer: Polymyositis Rationale: Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient's risk of falls and injury. Weakened pharyngeal muscles also increase the risk for aspiration, with interstitial lung disease in up to 65% of patients. Safety concerns and interstitial lung involvement are not associated with reactive arthritis (Reiter's syndrome) or Sjögren's syndrome. Safety may be an issue later in disease progression of SLE.

A nurse assesses a patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect? (Select all that apply.) Presence of nodules Consistent muscle strength Localized disease symptoms No destructive changes on x-ray Subluxation of joints without fibrous ankyloses Joint space narrowing and formation of osteophytes

Correct Answer: Presence of nodules Subluxation of joints without fibrous ankyloses Rationale: In stage III severe RA, extraarticular soft tissue lesions or nodules may be present along with subluxation without fibrous or bony ankylosis. Muscle strength is decreased because of extensive muscle atrophy. Manifestations are systemic rather than localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Joint space narrowing with osteophytes is consistent with osteoarthritis.

A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern should the nurse recommend? Bed rest with bathroom privileges Daily high-impact aerobic exercise Regular exercise program of walking Frequent rest periods with minimal exercise

Correct Answer: Regular exercise program of walking Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

Which nursing intervention is appropriate for a patient with Sjögren's syndrome? Ambulate with assistive devices. Use lubricating eyedrops frequently. Administer acetaminophen as needed. Apply ice or heat compresses to affected areas.

Correct Answer: Use lubricating eyedrops frequently. Rationale: Sjögren's syndrome is an autoimmune disorder in which lymphocytes attack moisture-producing glands. Treatment is symptomatic, including adding moisture to eyes and increasing intake of fluids, especially with meals.

5. In teaching a patient with systemic lupus erythematosus about the disorder, the nurse knows the pathophysiology includes a. circulating immune complexes formed from IgG autoantibodies reacting with IgG. b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer. c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles. d. the production of a variety of autoantibodies directed against components of the cell nucleus.

D Rationale: SLE is marked by production of many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins. Autoimmune reactions (antinuclear antibodies [ANA]) are typically directed against constituents of the cell nucleus, especially DNA.

A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments would be included in the plan of care? (Select all that apply.) Massage therapy Low-impact aerobic exercise Relaxation strategy (biofeedback) Antiseizure drug pregabalin (Lyrica) Morphine sulfate extended-release tablets Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

Massage therapy Low-impact aerobic exercise Relaxation strategy (biofeedback) Antiseizure drug pregabalin (Lyrica) Serotonin reuptake inhibitor (e.g., sertraline [Zoloft]) Rationale: Massage will improve blood flow and relaxation. Low-impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation using biofeedback may decrease the patient's stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will preferably be prescribed a nonopioid pain medication, an antiseizure medication such as pregabalin to help with widespread pain, and a serotonin reuptake inhibitor for depression. Long-acting opioids such as morphine are avoided unless other medications do not relieve pain.