Final exam practice question

Which female patients are at risk for developing osteoporosis (select all that apply)? a. 60-year-old white aerobics instructor b. 55-year-old Asian American cigarette smoker c. 62-year-old black who takes estrogen therapy d. 68-year-old white who is underweight and inactive e. 58-year-old Native American who started menopause prematurely

. b, d, e. Risk factors for osteoporosis include age >65 years, white or Asian ethnicity, cigarette smoking, low body weight, inactive lifestyle, and estrogen deficiency (either postmenopausal, or from premature or surgical menopause). Other factors include family history; diet low in calcium; vitamin D deficiency; excessive alcohol use; and long-term use of medications, such as corticosteroids, thyroid replacement, heparin, long-acting sedatives, or antiseizure drugs.

Patient-Centered Care: To preserve function and the ability to perform activities of daily living (ADLs), what should the nurse teach the patient with OA? a. Avoid exercise that involves the affected joints. b. Plan and organize task performance to be less stressful to joints. c. Maintain normal activities during an acute episode to prevent loss of function. d. Use mild analgesics to control symptoms when performing tasks that cause pain.

. b. Principles of joint protection and energy conservation are critical in being able to maintain functional mobility in the patient with OA. Help patients find ways to perform activities and tasks with less stress. ROM, isotonic, and isometric exercises of the affected joints should be balanced with joint rest and protection. During an acute flare of joint inflammation, the joints should be rested. If a joint is painful, it should be used only to the point of pain and masking the pain with analgesics may lead to greater joint injury

What laboratory findings should the nurse expect to be present in the patient with RA? a. Polycythemia b. Increased immunoglobulin G (IgG) c. Decreased white blood cell (WBC) count d. Antibodies to citrullinated peptide (anti-CCP)

10. d. The antibody to citrullinated peptide (anti-CCP) is more specific than RF for RA and may allow earlier and more accurate diagnosis. Other tests include C-reactive protein (CRP) that is elevated from inflammation of RA, a finding that is useful in monitoring the response to therapy. Anemia, rather than polycythemia, is common. Immunoglobulin G (IgG) levels are normal. The white blood cell (WBC) count may be increased in response to inflammation and is also elevated in synovial fluid.

After teaching a patient with RA about the prescribed therapeutic regimen, which patient statement indicates that further instruction is needed? a. "It is important for me to perform my prescribed exercises every day." b. "I should do most of my daily chores in the morning when my energy level is highest." c. "An ice pack to a joint for 10 minutes may help relieve pain when I have an acute flare." d. "I can use assistive devices, like padded utensils and elevated toilet seats, to protect my joints."

15. b. Most patients with RA have morning stiffness. Morning activities should be scheduled later in the day after the stiffness subsides. Taking a warm shower in the morning and allowing time to become more mobile before activity are advised. Ice for 10 minutes or splinting are helpful during increased disease activity. Management of RA includes daily exercises for the affected joints and protection of joints with devices and movements that prevent joint stress.

16. Patient-Centered Care: A patient recovering from an acute exacerbation of RA tells the nurse that she is too tired to bathe. What should the nurse do for this patient? a. Give the patient a bed bath to conserve her energy. b. Allow the patient a rest period before showering with the nurse's help. c. Tell the patient that she can skip bathing if she will walk in the hall later. d. Teach the patient that it is important for her to maintain self-care activities.

16. b. Pacing activities and alternating rest with activity are important in maintaining selfcare and independence of the patient with RA. These strategies also prevent deconditioning and improve patient attitude. The nurse should not complete activities for the patient but instead should support and assist the patient as necessary. A warm shower or sitting in a tub with warm water and towels over the shoulders may help relieve some stiffness.

17. After teaching a patient with RA to use heat and cold therapy to relieve symptoms, which patient statement indicates to the nurse that teaching has been effective? a. "Heat treatments should not be used if muscle spasms are present." b. "Cold applications can be applied for 25 to 30 minutes to relieve joint stiffness." c. "I should use heat applications for 25 minutes to relieve the symptoms of an acute flare." d. "When my joints are painful, using a bag of frozen corn for 10 to 15 minutes may relieve the pain."

17. d. Cold therapy is indicated to relieve pain during an acute inflammation. It can be applied for 10 to 15 minutes at a time with packages of frozen vegetables. Heat in the form of heating pads, moist warm packs, paraffin baths, or warm baths or showers is indicated to relieve stiffness and muscle spasm. Heat should not be applied for more than 20 minutes at a time.

18. The nurse teaches the patient with RA that which exercise is the most effective methods of aerobic exercise? a. Ballet dancing b. Casual walking c. Aquatic exercises d. Low-impact aerobic exercises

18. c. The best aerobic exercise is aquatic exercise in warm water. This allows easier joint movement because of the buoyancy of the water. Water produces more resistance and can strengthen the muscles. Tai Chi is a gentle, stretching exercise that would be appropriate. Dancing and walking impact the joints of the feet and even low-impact aerobics could be damaging. Exercises for the patient with RA should be gentle.

19. A patient is seen at the outpatient clinic for a sudden onset of inflammation and severe pain in the great toe. What establishes a definitive diagnosis of gouty arthritis? a. A family history of gout b. Elevated urine uric acid levels c. Elevated serum uric acid levels d. Presence of monosodium urate crystals in synovial fluid

19. d. The definitive diagnosis of gout is established by finding needle-like monosodium urate crystals in the synovial fluid of an inflamed joint or tophus. Although there is a familial predisposition to hyperuricemia, environmental and genetic factors contribute to gout. Hyperuricemia and elevated urine uric acid are not diagnostic for gout because they may be related to a variety of drugs or may exist as a totally asymptomatic abnormality in the general population.

20. During treatment of the patient with an acute attack of gout, which drug should the nurse expect to administer first? a. Aspirin b. Colchicine c. Probenecid d. Allopurinol

20. b. Colchicine has an antiinflammatory action specific for gout. It is the treatment of choice during an acute attack, often producing dramatic pain relief when given within 12 to 24 hours. Probenecid is a uricosuric drug used to control hyperuricemia by increasing the renal excretion of uric acid. Aspirin inactivates the effect of uricosuric drugs and should not be used when the patient is taking probenecid or other uricosuric drugs. Allopurinol, a xanthine oxidase inhibitor, is used to control hyperuricemia by blocking uric acid production

21. A patient with gout is treated with drug therapy to prevent future attacks. What should the nurse should teach the patient? a. Have periodic testing of serum uric acid levels. b. Avoid all foods high in purine, such as organ meats. c. Increase the dose of medication with the onset of an acute attack. d. Perform active range of motion (ROM) of all joints that are affected by gout.

21. b. During therapy with probenecid or allopurinol, the patient must have periodic determination of serum uric acid to evaluate therapy effectiveness and to ensure uric acid is kept low enough to prevent future gout attacks. With the use of medications, strict dietary restrictions on alcohol and high-purine foods are usually not necessary. When the patient is taking probenecid, urine output should be maintained at 2 to 3 L per day to prevent urate from precipitating in the urinary tract and causing kidney stones. The patient should not change the dose of medication without direction of the HCP. Drugs used for control of gout are not useful in the treatment of an acute attack. Joint immobilization is used for an acute attack of gout

What best describes the manifestations of OA? a. Smaller joints are typically affected first. b. There is joint stiffness after periods of inactivity. c. Joint stiffness is accompanied by fatigue, anorexia, and weight loss. d. Pain and immobility may be aggravated by falling barometric pressure

8. d. Pain and immobility of OA may be aggravated by falling barometric pressure. OA primarily first affects weight-bearing joints of knees and hips. Stiffness occurs on arising but usually resolves after 30 minutes. Pain during the day is relieved with rest. Fatigue, anorexia, and weight loss are nonspecific manifestations of the onset of RA.

During the physical assessment of the patient with early to moderate RA, what should the nurse expect to find? a. Hepatomegaly b. Heberden's nodes c. Spindle-shaped fingers d. Crepitus on joint movement

9. c. In early disease, the fingers of the patient with moderate RA may become spindle shaped from synovial hypertrophy and thickening of the joint capsule. The patient may not have joint deformities but may have limited joint mobility, adjacent muscle atrophy, and inflammation. Splenomegaly may be found with Felty syndrome in those with severe nodule-forming RA. Heberden's nodes and crepitus on movement are associated with OA.

Patient-Centered Care: A patient taking ibuprofen for treatment of OA has good pain relief but reports increased dyspepsia and nausea. What should the nurse discuss with the patient's health care provider (HCP) about these side effects? a. Adding misoprostol to the patient's drug regimen b. Substituting naproxen (Naprosyn) for the ibuprofen c. Returning to the use of acetaminophen at a dose of 5 g/day instead of 4 g/day d. Administering the ibuprofen with antacids to decrease the gastrointestinal (GI) irritation

a. Common side effects of nonsteroidal antiinflammatory drugs (NSAIDs) include gastrointestinal (GI) irritation and bleeding, dizziness, rash, headache, and tinnitus. Misoprostol is used to prevent NSAID-induced gastric ulcers. Gastritis and would increase the patient's tolerance of any of the NSAIDs. Naproxen could cause the same gastric effects as ibuprofen. It is generally recommended that the daily dose of acetaminophen should not exceed 3 g/day to prevent liver damage. Antacids interfere with the absorption of NSAIDs.

Which description is most characteristic of osteoarthritis (OA) when compared to rheumatoid arthritis (RA)? a. Not systemic or symmetric b. Rheumatoid factor (RF) positive c. Most commonly occurs in women d. Morning joint stiffness lasts 1 to several hours

a. OA is not systemic or symmetric. In OA, morning joint stiffness resolves in about 30 minutes. Rheumatoid arthritis (RA) is often rheumatoid factor (RF) positive, occurs more in women than men, is systemic, and affects small joints symmetrically. In RA, morning joint stiffness lasts 60 minutes to all day

A patient with OA asks the nurse if he could try glucosamine and chondroitin for symptom management. What is the best response by the nurse? a. Results of research have been mixed and most medical groups do not recommend their use. b. Most patients find these supplements helpful for relieving arthritis pain and improving mobility. c. These supplements are a fad that have not been shown to reduce pain or increase joint mobility. d. High dosages of these supplements are needed for the patient to receive any benefit in treating OA.

a. Results from studies on the use of glucosamine and chondroitin have been mixed. The American College of Rheumatology and American Academy of Orthopaedic Surgeons do not recommend their use. The nurse should encourage the patient to discuss all herbs and supplements with the HCP before taking them.

Patient-Centered Care: A patient is started on alendronate (Fosamax) once weekly for the treatment of osteoporosis. Which patient statement indicates that further instruction about the drug is needed? a. "I should take the drug with a meal to prevent stomach irritation." b. "This drug will prevent further bone loss and increase my bone density." c. "I need to sit or stand upright for at least 30 minutes after taking the drug." d. "I will still need to take my calcium supplements while taking this new drug."

a. The bisphosphonates, such as alendronate, must be taken with a full glass of water at least 30 minutes before food or other medications to promote their absorption. Because they are very irritating to the stomach and esophagus, the patient must remain upright for at least 30 minutes after taking these medications to prevent reflux into the esophagus. Although these drugs will prevent further bone loss and increase bone density, calcium and vitamin D supplementation is still needed for bone formation.

Identify ways to prevent osteoporosis in postmenopausal women (select all that apply). a. Eating more beef b. Eating 8 ounces of yogurt daily c. Performing weight-bearing exercise d. Spending 15 minutes in the sun each day e. Taking postmenopausal estrogen replacement

b, c. Increased calcium and vitamin D intake and weight-bearing exercises (i.e., walking) are the best methods to prevent osteoporosis in postmenopausal women. Beef is not high in calcium or vitamin D. Although 20 minutes in the sun each day provides vitamin D for most women, postmenopausal women should take supplemental vitamin D doses of 800 to 1000 IU per day. Although estrogen replacement may protect the woman against bone loss and fractures, it is no longer given specifically to prevent osteoporosis because of increased risk of heart disease and breast or uterine cancer.

14. A 70-year-old patient is being evaluated for symptoms of RA. What should the nurse recognize as the major problem in the management of RA in the older adult? a. RA is usually more severe in older adults. b. Older patients are not as likely to comply with treatment regimens. c. Drug interactions and toxicity are more likely to occur with multidrug therapy. d. Laboratory and other diagnostic tests are not effective in identifying RA in older adults.

c. The use of multidrug therapy in RA is particularly problematic in older adults because of the increased likelihood of adverse drug interactions and toxicity. Rheumatic disorders affect younger and older adults. Older adults are not less compliant with drug treatment but may need help with complex regimens. Interpretation of laboratory values in diagnosing RA in older adults is more difficult because of age-related serologic changes, but the disease can be diagnosed.

Priority Decision: A 60-year-old woman has pain on motion in her fingers and asks the nurse if this is just a result of aging. What information is the best response by the nurse? a. Joint pain with functional limitation is a normal change that affects all people to some extent. b. Joint pain that develops with age is usually related to previous trauma or infection of the joints. c. This is a symptom of a systemic arthritis that eventually affects all joints as the disease progresses. d. Changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age.

d. Cartilage destruction in the joints affects most adults by the age of 40 years. When the destruction becomes symptomatic, osteoarthritis (OA) is said to be present. Degenerative changes cause symptoms after age 50 or 60 years. More than half of adults over age 65 years have x-ray evidence of OA. Joint pain and functional disability are not to be considered a normal finding in aging persons. OA is not a systemic disease but may be caused by a known event or condition that directly damages cartilage or causes joint instability (e.g., menopause, obesity).

What is most likely to cause the pain experienced in the later stages of OA? a. Crepitation b. Bouchard's nodes c. Heberden's nodes d. Bone surfaces rubbing together

d. The pain in later OA is caused by bone surfaces rubbing together after the articular cartilage has deteriorated. Crepitation occurs earlier in the disease with loose particles of cartilage in the joint cavity. Bouchard's nodes and Heberden's nodes are tender; they occur as joint space decreases and appear as early as 40 years of age