Ch 50 Disorders of Musculoskeletal Function

A new patient arrives at the clinic. The physician is suspecting that the patient may have systemic lupus erythematosus (SLE) given the clinical manifestations related to joint pain, skin changes, and a history of pleural effusions. The nurse should anticipate which of the following diagnostic test will be a priority to facilitate with the diagnosis? A) Anti-DNA antibody test B) Routine hemoglobin C) C-reactive protein D) B-cell lymphocytes

Ans: A Feedback: Ninety-five percent of people with untreated SLE have high ANA levels. However, ANA is not specific for SLE. The anti-DNA antibody test is more specific for the diagnosis of SLE. Hemoglobin may be low if the patient has severe anemia, but it is not specific for SLE. C-reactive protein will show an inflammatory response but again not specific for SLE.

Which of the following individuals is most likely to develop a form of reactive arthritis? A) A 24-year-old male who completed treatment for a chlamydial infection 1 year ago B) A 46-year-old female who has a long-standing diagnosis of systemic lupus erythematosus C) A 3-year-old girl who was born with a 20-degree congenital scoliosis D) A 79-year-old male who had a total hip replacement 2 months prior

Ans: A Feedback: Reactive arthritis and Reiter syndrome, in particular, are precipitated by time-distant bacterial infections; Chlamydia trachomatis is frequently implicated. SLE, scoliosis, and hip fractures and/or surgery are not noted risk factors for the health problem.

Which of the following pathophysiological phenomena would be most indicative of ankylosing spondylitis? A) Loss of motion in the spinal column and eventual kyphosis B) A progressive loss of range of motion in the knee and hip joints C) A facial "butterfly rash" and multiorgan involvement D) Decreased bone density in long bones

Ans: A Feedback: The characteristic trait of ankylosing spondylitis is progressive loss of the spinal ROM and eventual kyphosis. Synovial joint involvement is not associated with the disease, and a butterfly rash and multisystem involvement are associated with SLE. Decreased bone density does not normally accompany ankylosing spondylitis.

A physician is attempting a differential diagnosis of a 30-year-old female who is suspected of having systemic lupus erythematosus (SLE). Which of the following aspects of the physician's assessment and the client's history would be considered potentially indicative of SLE? Select all that apply. A) The client has a "butterfly rash" on her nose and cheeks. B) She complains of intermittent joint pain. C) The woman states that she has numerous environmental allergies. D) The client has been hospitalized twice in the past for pleural effusions. E) Blood work indicates low red cells, white cells, and platelets.

Ans: A, B, D, E Feedback: A butterfly rash, joint pain, pleural effusion, and low levels of blood cellular components are all associated with SLE. Environmental allergies are not noted to be risk factors or associated symptoms of the disease.

While speaking to a senior citizen club about osteoarthritis (OA), which of the following facts are accurate to share? Select all that apply. A) By the time you are in your 70s, about 85% of adults will have some form of OA B) Men usually get OA in their hands, whereas women get OA primarily in their hips C) Obesity in women has been correlated to having OA in the knees D) Heredity does not play a significant role in the development of OA

Ans: A, C Feedback: Eighty-five percent of people with OA are in their 70s. Men are affected more commonly at a younger age. Heredity influences the occurrence of hand OA in the DIP joint. Hand OA is more likely to affect white women, whereas knee OA is more common in black women. Obesity is a particular risk factor for OA of the knee in women.

When educating the patient with ankylosing spondylitis, the nurse should emphasize which of the following treatment interventions? Select all that apply. A) Encourage sleeping supine on an extra firm mattress if possible. B) Prop self up in bed with extra pillows if having respiratory congestion. C) Try using the heating pad prior to exercise to help stretching and improve movement. D) Wear a knee immobilizer while biking to facilitate ability to exercise for longer periods. E) Modify diet to include more protein from red meats and green vegetables for vitamin K.

Ans: A, C Feedback: Treatment of ankylosing spondylitis is directed at controlling pain and maintaining mobility by suppressing inflammation. Proper posture and position are important. This includes sleeping in a supine position on a firm mattress using one small pillow. Therapeutic exercises are important. Heat applications or a shower or bath may be beneficial before exercise to improve ease of movement. Swimming is an excellent exercise. Immobilizing joints is not recommended. Maintaining ideal weight reduces the stress on weight-bearing joints. However, dietary changes are usually very individualized.

Although the client's primary care provider has downplayed the symptoms, a geriatrician suspects that an 82-year-old female has polymyalgia rheumatica. Which characteristic symptomatology would most likely have led the specialist to suspect this health problem? A) Extended periods of walking cause pain that extends from her ankles, knees, and sciatic nerve. B) The woman complains of aching and morning stiffness in her neck, shoulder, and pelvis. C) Range of motion in the woman's wrists and ankles is greatest in the morning and decreases over the course of a day. D) The woman's metatarsal joints are inflamed and sensitive to touch.

Ans: B Feedback: Polymyalgia rheumatica is an inflammatory condition of unknown origin characterized by aching and morning stiffness in the cervical regions and shoulder and pelvic girdle areas. Lower limb pain, wrist and ankle stiffness, and pain in the joints of the foot would not be as clearly suggestive of polymyalgia rheumatica.

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? A) Inappropriate T-cell-mediated immune responses have resulted in articular cartilage degeneration. B) Loss of articular cartilage and synovitis has resulted from inflammation caused when joint cartilage attempted to repair itself. C) Excessive collagen deposits have accumulated in the woman's synovial joints. D) Bone overgrowth in synovial joints has resulted in fusing of adjacent bones that normally articulate.

Ans: B Feedback: The joint changes associated with osteoarthritis, which include a progressive loss of articular cartilage and synovitis, result 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.

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 male client has elevated levels of serum uric acid but lacks symptoms. B) Synovial fluid aspiration indicates the presence of monosodium urate crystals. C) A man reveals that he eats organ meat two to three times weekly. D) A 55-year-old male reveals that it takes a day or two for oral colchicines to relive his attacks of gout.

Ans: B Feedback: 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 male patient in his 50s has just been diagnosed with hyperuricemia. He has had multiple flare-ups of his first metatarsophalangeal joint pain and swelling. The pain is so severe that he cannot sleep with any covers/sheets over his feet at night. The nurse should anticipate that the patient will likely be prescribed: Select all that apply. A) Tylenol (acetaminophen) for the pain. B) allopurinol (Zyloprim) to decrease uric acid levels. C) calcium carbonate used to increase the intake of calcium. D) Anturane (sulfinpyrazone) to increase excretion of urate. E) sevelamer (Renagel) to reduce the absorption of phosphate.

Ans: B, D Feedback: Treatment of hyperuricemia is aimed at maintaining normal uric acid levels and is lifelong. One method is to reduce hyperuricemia through the use of allopurinol. Allopurinol inhibits xanthine oxidase, an enzyme needed for the conversion of hypoxanthine to xanthine and xanthine to uric acid as does a newer medication, Febuxostat. The uricosuric drugs (sulfinpyrazone) prevent tubular reabsorption of urate and increase its excretion in the urine. NSAIDs, not Tylenol, are usually prescribed for the pain. Calcium does not play a factor in gout. Sevelamer (Renagel), to reduce the absorption of Phosphate, is primarily used in renal failure patients.

A 16-year-old boy has been diagnosed with ankylosing spondylitis. Which of the following etiologies is responsible for his health problem? A) Infection B) Friction between bones C) Immune response D) Inappropriate bone remodeling

Ans: C Feedback: Ankylosing spondylitis is thought to have an etiology that suggests an immune response. Physical wear and tear, infection, and inappropriate remodeling are not considered primarily responsible for the disease.

A 7-year-old boy has been diagnosed with juvenile idiopathic arthritis (JIA), and his parents are anxious to know how his health problem will affect his short-term and longer-term future. What can his health care provider most accurately tell the family? A) "Because JIA is an autoimmune disease, the long-term prognosis is quite poor and his mobility is likely to decline over time." B) "The earlier that we can schedule joint replacement surgeries, the better his prognosis will be." C) "With appropriate use of anti-inflammatory drugs along with lifestyle modifications, your son stands a good chance of leading a normal life." D) "We can relieve many of the symptoms or JIA and ensure his mobility, but there is a risk he'll develop a systemic immune response beyond his joints."

Ans: C Feedback: NSAIDs, biologic response modifiers, and lifestyle modifications allow for a positive prognosis with most cases of JIA. Surgery is not necessarily indicated, and JIA is not noted to precipitate a systemic immune response.

The physician is considering prescribing an anti-tumor necrosis factor (TNF) like infliximab for a rheumatoid arthritis patient. Which of the following statements is accurate about the advantages of using a TNF inhibitor? A) "Since TNF inhibitors have few side effects, these drugs will fit well into your regimen." B) "Your disease-modifying antirheumatic drug (DMARD) methotrexate has more cardiovascular side effects than TNF inhibitors." C) "TNF inhibitors help slow the disease progression and improve your ability to perform routine ADL functions." D) "Not only do TNF inhibitors control your disease better but they also will interrupt the inflammatory cascade at several levels."

Ans: C Feedback: Second-line antirheumatic drugs include anti-TNF drugs such as etanercept, infliximab, and adalimumab. These drugs are biologic response-modifying agents or TNF inhibitors that block TNF-a, one of the key proinflammatory cytokines in RA. Anti-TNF-a agents have shown significant efficacy although they do have some potential adverse side effects. Evidence indicates that CV side effects are not different for TNF inhibitors than for DMARDs. The TNF inhibitor agents also have been shown to inhibit radiologic disease progression and improve functional outcomes.

A 44-year-old woman who has a long-standing diagnosis of SLE has been able to control her symptoms with lifestyle modifications for several years, but has presented to her care provider due to recent exacerbation. Which of the following pharmacological treatment options is her care provider most likely to rule out first? A) Nonsteroidal anti-inflammatory drugs B) Corticosteroids C) Antiplatelet aggregators D) Immunosuppressive drugs

Ans: C Feedback: While NSAIDs, corticosteroids, and immunosuppressives are all noted treatment options for SLE, antiplatelet aggregators are unlikely to address the etiology or signs and symptoms of the disease. A new drug that has shown positive effects in decreasing inflammatory exacerbations for people with SLE is Belimumab, which is a monoclonal antibody that inhibits B-lymphocyte stimulator.

A 68-year-old woman has had her mobility and quality of life severely affected by rheumatoid arthritis (RA). Place the following pathophysiological events involved in her health problem in the correct order that they most likely occurred. Use all the options. A) Inflammatory response B) Interaction between rheumatoid factor (RF) and IgG C) T-cell-mediated immune response D) Pannus invasion E) Destruction of articular cartilage

Ans: C, B, A, D, E Feedback: RA is thought to begin with a T-cell-mediated immune response that precipitates interaction between IgG and RF that constitutes an immune response. Pannus invasion is one consequence of this interaction, the ultimate result of which is destruction of cartilage.

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 effects 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'm really trying to lose weight, and I've been able to lose 15 lb this year so far." B) "I've been doing muscle-strengthening exercises twice a week at the community center near my house." C) "Even though I don't like it, I've been using my walker to take some of the weight off my knees." D) "I've been avoiding painkillers because I know they can mask damage that I might be inflicting on my knees."

Ans: D Feedback: 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.

Following a progressive onset of fatigue, aching, and joint stiffness over the last 2 years, a 69-year-old male has recently been diagnosed with rheumatoid arthritis (RA). Which of the following teaching points should his primary care physician include during the office visit in which this diagnosis is communicated to the client? A) "The symptoms you've been experiencing are the result of damage inside your joints, but I'll start you medications that will reverse this damage." B) "It's important that you maximize your level of activity, since decreasing your mobility will worsen the disease." C) "The best treatment plan is to try all other available treatments before resorting to using medications." D) "Steroids and anti-inflammatory drugs that I'll prescribe will likely bring some relief to your symptoms."

Ans: D Feedback: Current treatment guidelines for RA involve early and aggressive pharmacological treatment, including NSAIDs and corticosteroids. Damage cannot be reversed, and while therapeutic exercise plays a role in treatment, rest is also important.

When working with a patient with diffuse scleroderma who is exhibiting a "stone face" expression, the nurse should consider which of the following to be a priority nursing diagnosis for this patient? A) Ineffective tissue perfusion related to tightening of the facial skin B) Activity intolerance related to muscle tightening in lower extremities C) Oral mucous membrane, impaired due to restricted motion of the mouth D) Aspiration, risk related to swallowing impairments

Ans: D Feedback: Diffuse scleroderma is characterized by severe and progressive disease of the skin and the early onset of organ involvement. The typical person has a "stone facies" due to tightening of the facial skin with restricted motion of the mouth. Involvement of the esophagus leads to hypomotility and difficulty in swallowing. The other NANDAs would be of lower priority if at all given the assessment data presented.

An 8-year-old child has just been diagnosed with systemic lupus erythematosus (SLE). The parents wonder what the child's prognosis is going to be. Which of the following findings would be considered a good prognostic indicator of the extent/seriousness of the disease? A) Complaints of arthralgias and arthritis in joints with movement B) Ligaments and tendons hurt during passive ROM C) Has a rash on the nose and cheeks D) Swelling in the face and eyes and rust/blood-colored urine

Ans: D Feedback: The clinical manifestations of SLE in children reflect the extent and severity of systemic involvement. The best prognostic indicator in children is the extent of renal involvement, which is more common and more severe in children than in adults with SLE. Edema and rusty or bloody urine are classic signs of glomerulonephritis. It is expected that people/children with SLE have arthralgias/arthritis in joints, sore ligaments and tendons, as well as integumentary signs and symptoms like a rash on the nose and cheeks (butterfly rash).

A 36-year-old female who has experienced diverse symptoms for several years has finally had her health problems attributed to scleroderma (systemic sclerosis) and has committed herself to learning as much about the disease as she can. Which of her following statements would her nurse want to correct or clarify? A) "I'm surprised that in this day and age, they still don't know what causes scleroderma." B) "I suppose this explains why I have such terrible circulation to my hands and feet." C) "I'm scared by the damage that this could cause to my heart and lungs." D) "The worst part of this so far has been learning that there aren't any treatments for scleroderma."

Ans: D Feedback: While the cause of scleroderma remains unknown, supportive treatments that address symptoms do exist. Reynaud phenomenon is a very common accompaniment to the disease, and cardiac and pulmonary involvement is common.