NSG 245 Ch 38- Assessment & Management Rheumatic Disorders

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?

Visual changes 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.

The nurse is planning teaching for a client with gout. Which topics will the nurse include in the teaching? Select all that apply.

Weight loss Decreasing alcohol intake Avoiding purine-rich foods Management between the attacks of gout include lifestyle changes to include weight loss, decreasing alcohol intake, and avoiding purine-rich foods. Exercise does not need to be limited and water does not need to be restricted.

A decrease in this can be seen in chronic inflammation

hematocrit

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?

Arrange for the patient to be assessed in her home environment. Assessment in the patients 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.

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?

Decreased platelets 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.

A client is diagnosed with primary hyperuricemia. Which information in the client's health history will the nurse use to substantiate this diagnosis? Select all that apply.

Has daily intake of shellfish Has a family history of hyperuricemia Gout is caused by hyperuricemia (increased serum uric acid). Primary hyperuricemia may be caused by excessive intake of foods that are high in purines such as shellfish. It can also be caused by genetics. Furosemide, treatment for psoriasis, and taking low-dose salicylates are associated with secondary hyperuricemia.

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 womans care needs?

Ineffective Role Performance Related to Pain Typically, patients with fibromyalgia have endured their symptoms for a long period of time. The neuropathic pain accompanying FM can often impair a patients ability to perform normal roles and functions.

Which joint is most commonly affected in gout?

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

The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about?

Methotrexate Methotrexate is a DMARD that reduces the amount of joint damage and slows the damage to other tissues as well. Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID). Methylprednisolone is a steroid to reduce pain and inflammation and slow joint destruction. Mercaptopurine azathioprine is a cytotoxic drug.

The nurse is caring for a client with ankylosing spondylitis (AS). Which medication will the nurse expect to be prescribed for this client?

Nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs are the first-line therapy for treating all spondyloarthropathies. Antibiotics and anticoagulants are not used to treat AS. Corticosteroid injections may be used for periodic flares; however, oral and long-term use of steroids is not recommended.

A client is experiencing symptoms of giant cell arteritis (GCA). Which action will be taken to definitively diagnose this condition?

Obtain the results of a temporal artery biopsy. The diagnosis of GCA can be difficult because of the lack of specificity of tests. However, in the case of GCA, biopsy of the temporal artery is the definitive diagnostic tool. The C-reactive protein can be used to diagnose GCA if other clinical findings are present. The response to corticosteroids may be considered as diagnostic for GCA and polymyalgia rheumatica. A markedly high erythrocyte sedimentation rate is a screening test but is not definitive for GCA.

A 40-year-old woman was diagnosed with Raynauds 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?

Scleroderma Scleroderma starts insidiously with Raynauds 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.

A client is taking ibuprofen for the treatment of osteoarthritis. What education will the nurse give the client about the medication?

Take the medication with food to avoid stomach upset. Ibuprofen is a nonsteroidal anti-inflammatory drug. The nurse should advise the patient to take NSAIDs with food to avoid stomach upset. Ibuprofen is available over the counter, but it still has side effects. Aspirin is known to cause ringing in the ears, not NSAIDs.

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?

I'll make sure to monitor my body temperature on a regular basis. 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.

What intervention is a priority for a client diagnosed with osteoarthritis?

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

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?

Arthocentesis 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 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?

To avoid complications such as blindness 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.

Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage?

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.

A patient comes to the clinic with an inflamed wrist. How should the nurse splint the joint to immobilize it?

slight dorsiflexion

The nurse is educating the patient with gout about ways to prevent reoccurrence of an attack. What foods should the nurse encourage the patient to avoid?

steak

In the inflammatory process in rheumatic diseases, a triggering event starts the process by activating-

T-lymphocytes

A patient with an acute exacerbation of arthritis is temporarily confined to bed. What position can the nurse recommend to prevent flexion deformities?

prone

A patient is receiving gold sodium thiomalate for the treatment of RA. What does the nurse understand about the action of this compound?

the drug inhibits T- and B-cell activity

An increase in this substance is seen with gout

uric acid

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?

"My finger joints are oddly shaped." Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.

An older adult with rheumatoid arthritis says exercise was not effective. Which response will the nurse make to learn the reason for the failure of this treatment approach?

"What types of exercise were you doing?" In an older adult with rheumatoid arthritis, exercise programs may not be instituted or may be ineffective because the client expects results too quickly or fails to appreciate the effectiveness of a program of exercise. Strength training is encouraged in the older adult with chronic diseases. The other questions will not help the nurse understand what type of exercise was used and what it was not effective for the client.

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be?

Administering ordered analgesics and monitoring their effects An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management her priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions don't not take priority over pain management.

Which of the following procedures involves a surgical fusion of the joint?

Arthrodesis An arthrodesis is a surgical fusion of the joint. Synovectomy is the excision of the synovial membrane. Tenorrhaphy is the suturing of a tendon. An osteotomy alters the distribution of the weight within the joint.

This test is frequently positive for RA and SLE

C-reactive protein (CRP)

The nurse is educating a client about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms to report. Which COX-2 inhibitor is the nurse educating the client about?

Celecoxib The COX-2 inhibitor celecoxib (Celebrex) is associated with an increased risk of cardiovascular events, including myocardial infarction and stroke.

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find?

Elevated erythrocyte sedimentation rate The erythrocyte sedimentation rate (ESR) may be elevated, particularly as the disease progresses. ESR shows inflammation associated with RA. Red blood cell count and C4 complement component are decreased. Serum protein electrophoresis may disclose increased levels of gamma and alpha globulin but decreased albumin.

A nurse assesses a client in the health care provider's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?

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.

The client with osteoarthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?

Has a weight gain of 5 pounds Obesity is a risk factor for osteoarthritis. Excess weight is a stressor on the weight-bearing joints. Weight reduction is often a part of the therapeutic regimen.

A patient is prescribed a DMARD that is successful in the treatment of rheumatoid arthritis but has side effects, including retinal eye changes. What medication is it?

Hydroxychloroquine

Which assessment suggests to the nurse that a client with systemic lupus erythematous is having renal involvement?

Hypertension Hypertension is suggestive of renal damage in the client with systemic lupus erythematous.

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?

Increased uric acid levels Gout is caused by hyperuricemia (increased serum uric acid).

Scleroderma typically begins with the involvement of which system?

Integumentary

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?

Joint stiffness, especially in the morning 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 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?

Methotrexate (Rheumatrex) 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 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.

PMR has an association with the genetic marker HLA-DR4. Immunoglobulin deposits occur in PMR. PMR occurs predominately in Caucasians. 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.

The nurse is completing the physical assessment of a client with systemic lupus erythematosus (SLE). Which finding will the nurse recognize is most likely to indicate that the client is experiencing a change to the cardiovascular system because of the condition?

Pericardial friction rub The cardiac system is also commonly affected in SLE. Auscultating a pericardial friction rub would indicate myocarditis. Peripheral edema, jugular vein distention, and bounding peripheral pulses are not symptoms that indicate SLE is affecting the cardiovascular system.

A patient is seen in the office for reports of joint pain, swelling, and a low-grade fever. What blood studies does the nurse know are consistent with a positive diagnosis of RA? (SATA)

Positive C-reactive protein (CRP) Positive antinuclear antibody (ANA) Serum complement level (C3) of >130 mg/dL

A nurses 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?

Preserve and increase range of motion while limiting joint stress 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.

The nurse is caring for a patient who presents with the symptom of blanching fingers when exposed to cold. What rheumatic disorder does the nurse prepare to assess the patient for?

Raynaud phenomenon

A patients 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?

Rheumatoid arthritis (RA) 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 caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patients care, what goal should the nurse include?

The patient will express satisfaction with her ability to perform ADLs. 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 client is recovering from an attack of gout. What will the nurse include in the client teaching?

Weight loss will reduce uric acid levels and reduce stress on joints. Weight loss will reduce uric acid levels and reduce stress on joints. Weight loss will not reduce purine levels, reduce inflammation, or increase uric acid levels.

The nurse is reviewing the medication administration record of the client. Which medication would lead the nurse to suspect that the client is suffering from an acute attack of gout?

colchicine

The nurse is caring for a client with a new onset of gout. What medication does the nurse anticipate will be ordered by the health care provider?

colchicine The treatment of gout involves managing the acute inflammatory stage, preventing flare-ups, and controlling hyperuricemia. Colchicine, along with indomethacin, ibuprofen, or a corticosteroid, is prescribed to relieve an acute attack of gout. Probenecid and anturane increase the urinary excretion of uric acid, and allopurinol breaks down purines before uric acid is formed.

A patient is being placed on a purine-restricted diet. What food should be suggested by the nurse?

dairy products

The nurse is gathering a health history for a client with osteoarthritis. What clinical manifestation will the nurse expect to find?

early morning stiffness Explanation: Osteoarthritis is characterized by early morning stiffness that decreases with activity. Large joints are usually involved with osteoarthritis. Joint pain is a constant with osteoarthritis. Clients with rheumatoid arthritis have subcutaneous nodules.

A client is being treated for hyperuricemia. Part of the treatment strategy is for the client to avoid contributing factors whenever possible. Which activities might bring on an acute attack?

eating organ meats and sardines During an acute attack, high-purine foods are avoided, including organ meats, gravies, meat extracts, anchovies, herring, mackerel, sardines, and scallops. The other listed factors do not worsen attacks.

The nurse is completing a health history with a client in a clinic. What assessment finding best correlates with a diagnosis of osteoarthritis?

joint stiffness that increases with activity A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that increases 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.

A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include?

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. The nodules are not reddened.

A patient is suspected of having myositis. The nurse prepares the patient for what procedure that will confirm the diagnosis?

muscle biopsy

A diet plan is developed for a client with gouty arthritis. What should the nurse advise the client to limit the intake of?

organ meats Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, chocolate, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis.

The most common symptom of rheumatic disease that causes the patient to seek medical attention is-

pain

This is present in 80% of those with RA

rheumatoid factor

In RA, the autoimmune reaction primarily occurs in the-

synovial tissue

This is present in 85% of those with ankylosing spondylitis

HLA-B27 antigen

A client has a serum study that is positive for the rheumatoid factor. What will the nurse tell the client about the significance of this test result?

It is suggestive of rheumatoid arthritis. Rheumatoid factor is present in about 70% to 80% of patients with rheumatoid arthritis, but its presence alone is not diagnostic of rheumatoid arthritis, and its absence does not rule out the diagnosis. The antinuclear antibody (ANA) test is used to diagnose Sjögren's syndrome and systemic lupus erythematosus.

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine positivity for the disorder. Which statement by the nurse is most accurate?

"The diagnosis won't be based on the findings of a single test but by combining all data found." There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the health care provider, stating that SLE is a serious systemic disorder, and asking the client to express feelings about the potential diagnosis do not answer the client's question.

The nurse is assessing a patient with a diagnosis of scleroderma. What clinical manifestations of scleroderma does the nurse assess? (SATA)

Decreased ventilation owing to lung scarring Dysphagia owing to hardening of the esophagus Dyspnea owing to fibrotic cardiac tissue

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?

Facilitate referrals to occupational and physical therapy 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 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?

Fatigue Related to Pain Fibromyalgia is characterized by fatigue, generalized muscle aching, and stiffness.

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?

The patients body mass index is 34 (obese). 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 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 patients health should the nurse focus most closely during the visit?

The patients functional status The patients functional status is a central focus of home assessment of the patient with RA. The nurse may also address the patients understanding of the disease, complications, and social support, but the patients level of function and quality of life is a primary concern.

A client is experiencing painful joints and changes in the lungs, heart, and kidneys. For which condition will the nurse schedule this client for diagnostic tests?

Autoimmune disorders A hallmark of inflammatory rheumatic diseases is autoimmunity, where the body mistakenly recognizes its own tissue as a foreign antigen. Although focused in the joints, inflammation and autoimmunity also involve other areas. The blood vessels (vasculitis and arteritis), lungs, heart, and kidneys may be affected by the autoimmunity and inflammation. It is unlikely that the client's array of symptoms is being caused by heart disease, vascular diseases, or metabolic disorders.

A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed cyclophosphamide (Cytoxan). The nurses subsequent assessments should address what potential adverse effect?

Infection 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.

Osteoarthritis is known as a disease that

is the most common and frequently disabling of joint disorders. The functional impact of osteoarthritis on quality of life, especially for elderly clients, is often ignored. Reiter syndrome is a spondyloarthropathy that affects young adult males and is characterized primarily by urethritis, arthritis, and conjunctivitis. Psoriatic arthritis, characterized by synovitis, polyarthritis, and spondylitis, requires early treatment because of early damage caused by disease. Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues, making them rigid and decreasing mobility; it is usually diagnosed in the second or third decade of life.

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?

Gold-containing compounds Stomatitis is an adverse effect that is associated with gold therapy.

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?

Restrict consumption of foods high in purines 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 patient with SLE asks the nurse why she has to come to the office so often for check-ups. What would be the nurses best response?

Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working. 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 patients question. Blood work is not necessarily drawn monthly and assessing medication adherence is not the sole purpose of visits.

The nurse teaches the client that osteoarthritis

is the most common and frequently disabling of joint disorders. The functional impact of osteoarthritis on quality of life, especially for elderly clients, is often ignored. Reiter syndrome is a spondyloarthropathy that affects young adult males and is characterized primarily by urethritis, arthritis, and conjunctivitis. Psoriatic arthritis, characterized by synovitis, polyarthritis, and spondylitis, requires early treatment because of early damage caused by disease. Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues and is usually diagnosed in the second or third decade of life.

A client asks the nurse how their rheumatoid arthritis is diagnosed. The nurse knows that which finding from diagnostic tests can be used to diagnose rheumatoid arthritis?

Boney erosions on x-ray The American College of Rheumatology and the European League Against Rheumatism have established criteria for classifying RA. These criteria are based on a point system where a total score of 6 or greater is required for the diagnosis of RA. Clients diagnosed with RA who are excluded from these diagnostic criteria include those with bony erosions on X-ray. RA is not diagnosed by CT scans, MRIs, or arteriograms, however CT scans and MRIs can be used to detect bone erosions and inflammatory changes of rheaumatoid arthritis.

A client with osteoarthritis expresses concerns that the disease will prevent the ability to complete daily chores. Which suggestion should the nurse offer?

"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 oneself during daily activities. Telling the client to do 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 oneself and take frequent rests rather than doing all chores at once.

The nurse intervenes to assist the client with fibromyalgia to cope with which symptoms?

Chronic fatigue, generalized muscle aching, and stiffness Fibromyalgia is a common condition that involves chronic fatigue, generalized muscle aching, and stiffness. The cause is unknown, and no pathologic characteristics specific for the condition have been identified. Treatment consists of attention to the specific symptoms reported by the client. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants are used to improve or restore normal sleep patterns, and individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in these individuals.

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?

I have this ringing in my ears that just wont go away.

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?

Raynauds phenomenon The R in CREST stands for Raynauds phenomenon.

A nurse is providing care for a patient who has a rheumatic disorder. The nurses comprehensive assessment includes the patients mood, behavior, LOC, and neurologic status. What is this patients most likely diagnosis?

Systemic lupus erythematosus (SLE) 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 patients rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary care provider has added prednisone to the patients drug regimen. What principle will guide this aspect of the patients treatment?

The drug should be used for as short a time as possible. 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 patient has a serum study that is positive for the rheumatoid factor. What does the nurse understand is the significance of this test result?

The test results are suggestive of rheumatoid arthritis

The nurse is teaching a client about rheumatic disease. What statement best helps to explain autoimmunity?

"Your symptoms are a result of your body attacking itself." In autoimmunity, the body mistakes its own tissue for foreign tissue and begins to attack it. Symptoms develop as the body destroys tissue. The body is in effect attacking itself. The other statements do not explain autoimmunity.

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?

Assessment for headaches and jaw pain 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 client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included?

Delaying exercise for 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.

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 patients adherence to her medication regimen?

Encourage her to have her pharmacy replace the tops with alternatives that are easier to open. The patients pharmacy will likely be able to facilitate a practical solution that preserves the patients independence while still fostering adherence to treatment.

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

Erythrocyte sedimentation rate C-reactive protein 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 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?

Fatigue Related to Anemia 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 caring for a client with palindromic rheumatism. The nurse knows that this type of rheumatism can lead to which diagnosis?

Rheumatoid arthritis Palindromic rheumatism is an uncommon variety of recurring and acute arthritis and periarthritis that in some may progress to rheumatoid arthritis (RA) but is characterized by symptom-free periods of days to months. Because of this, the nurse should plan care that would be similar to the client with RA. The symptoms of palindromic rheumatism are not similar to those of scleroderma, fibromyalgia, or systemic lupus erythematosus.

The rheumatoid arthritis reaction produces enzymes that break down-

collagen

This protein substance is decreased in RA and SLE

complement

An increase in this may indicate renal damage, as in scleroderma

creatinine

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 nurses response to the patient?

Evidence shows minimal benefits from most CAM therapies. 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 with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient expresses anger and irritation when her call bell isn't answered immediately. What would be the most appropriate response?

You seem like youre feeling angry. Is that something that we could talk about? 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 doesnt acknowledge her feelings. Ignoring the patients 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 patients feelings.

The nurse is assessing a client with a history of ankylosing spondylitis. What will the nurse most commonly assess?

low back pain The most common symptoms of ankylosing spondylitis are low back pain and stiffness. A red, butterfly-shaped rash on the face and a patchy loss of hair are associated with systemic lupus erythematosus. Ankylosing spondylitis does not affect urine output.

Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia

may feel as if their symptoms are not taken seriously.

Synovial fluid from an inflamed joint is characteristically (select all that apply)

milky cloudy dark yellow

The nurse is planning care in the home for a client with rheumatoid arthritis. What instruction(s) should the nurse include in the plan of care? Select all that apply.

Collaborate with occupational therapists for specialized equipment. Identify the exercise regimen planned by physical therapist. Provide nursing assistance for ADLs. Ensure the home environment is safe. The nurse should collaborate with occupational therapists for specialized equipment, identify the exercise regimen planned by physical therapist, provide nursing assistance for ADLs, and ensure the home environment is safe. The nurse should teach the nursing assistant to allow extra time in the morning, not the evening, for hygiene or other procedures.

A patient with SLE has come to the clinic for a routine check-up. When auscultating the patients apical heart rate, the nurse notes the presence of a distinct scratching sound. What is the nurses most appropriate action?

Inform the primary care provider that a friction rub may be present 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 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?

OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints. 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 caring for a client with a warm and painful toe from gout. What medication will the nurse administer?

colchicine A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The health care provider orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide is a diuretic; it is not used to relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it is not used to treat gout.

The nurse is teaching a newly diagnosed client about systemic lupus erythematosus(SLE). What statement by the client indicates the teaching was successful?

"The belief is that it is an autoimmune disorder with an unknown trigger." Systemic lupus erythematosus is believed to be an autoimmune disorder but the triggering mechanism is not known. The disorder is more common in women than in men, most with the disorder in the 3rd or 4th decade of life. The disease is considered the "great imitator" because the clinical signs resemble many other conditions. SLE is a diffuse connective tissue disease that affects multiple body systems.

What is the priority intervention for a client who has been admitted repeatedly with attacks of gout?

Assess diet and activity at home Clients with gout need to be educated about dietary restrictions in order to prevent repeated attacks. Foods high in purine need to be avoided, and alcohol intake has to be limited. Stressful activities should also be avoided. The nurse should assess to determine what is stimulating the repeated attacks of gout. The other interventions are not appropriate for a client with this problem.

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?

Butterfly rash 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 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?

Gastrointestinal 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 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?

Limiting intake of alcohol 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 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.

Managing Raynauds-type symptoms Smoking cessation The importance of vigilant skin care patient teaching for the patient with scleroderma focuses on management of Raynauds phenomenon, smoking cessation, and meticulous skin care. Surgical treatment options do not exist and weight loss is not a central concern.

A 21-year-old male has just been diagnosed with a spondyloarthropathy. What will be a priority nursing intervention for this patient?

Teaching about symptom management 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 nurse is managing the care of a client with osteoarthritis. What is the appropriate treatment strategy the nurse will teach the about for osteoarthritis?

administration of nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs are routinely used for anti-inflammatory and analgesic effects. NSAIDs reduce inflammation, which causes pain. Opioids aren't used for pain control in osteoarthritis. Intra-articular injection of corticosteroids is used cautiously for an immediate, short-term effect when a joint is acutely inflamed. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.

A positive test for this is associated with systemic lupus erythematosus (SLE), RA, and Raynaud disease

antinuclear antibody (ANA)

A client was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. What would not be a part of teaching plan for this condition?

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.