Ch 50 Porth's
The parents of a child diagnosed with rheumatic disease are shocked by the diagnosis and tell the nurse that they did not think children could acquire the disease. The best response would be:
"Children can be affected with almost all of the rheumatic diseases that occur in adults." Explanation: Children can be affected by many of the same types of rheumatic diseases that occur in adults. The disease may affect both child and family and can seriously impact a child's growth and development, limit the child's participation in childhood activities, and require an extensive plan of drug treatment and rehabilitation.
A client has been diagnosed with rheumatoid arthritis (RA). What will the nurse tell the client about this disorder's etiology?
"Genetic predisposition is very likely." Explanation: The cause of RA is uncertain but evidence points to genetic predisposition. The disease usually occurs later in life.
A 64-year-old man was diagnosed 19 months ago with bilateral osteoarthritis (OA) in his knees, and has come to his family physician for a checkup. The client and his physician are discussing the effects of his health problem and the measures that the man has taken to accommodate and treat his OA in his daily routines. Which statement by the client would necessitate further teaching?
"I've been avoiding painkillers because I know they can mask damage that I might be inflicting on my knees." Explanation: Analgesics are a common and appropriate treatment for OA, and it would be unnecessary and inappropriate to forego pain control in order to maximize pain signals from affected joints. Weight loss, the use of assistive devices, and muscle-strengthening exercises are appropriate treatments for OA.
A nurse is teaching a group of nursing students about the presentation of systemic lupus erythematosus (SLE). Which statement is the nurse likely to make?
"More women than men are affected by lupus." Explanation: There is a female predominance of 10:1 in those with SLE. This ratio is closer to 30:1 during childbearing years. SLE is more common in blacks, Hispanics, and Asians than in whites, and the incidence in some families is higher than in others.
The nurse determines that additional client education is needed when a client with gout makes which statement?
"When I have an exacerbation of my symptoms, a glass of red wine will be helpful." Explanation: The statement about drinking alcohol to decrease the symptoms would need more follow-up, since it is a strong contributor to an exacerbation of gout. The other statements are valid.
The nurse is caring for several clients on an orthopedic unit. Place the clients listed in the order in which the nurse should assess them. Use all options.
77-year-old with osteoarthritis who has just returned from total knee arthroplasty. 56-year-old with rheumatoid arthritis with a temperature of 101.3°F (38.5°C). 24-year-old with ankylosing spondylitis with acute pain radiating from spine to thigh. 89-year-old with polymyalgia rheumatica who currently has corticosteroids infusing. Explanation: First, the nurse should assess the postoperative client to ensure all postoperative treatments and assessments are completed, given the high safety risk in this immediate postoperative period. Second, the nurse should assess the client with rheumatoid arthritis and a fever. These clients are at risk for infection which could progress to sepsis if not treated promptly. Third, the nurse should assess the client with ankylosing spondylitis. Though this type of pain is typical of the condition and does not raise concerns about an acute complication, the client's comfort should be addressed. Lastly, the nurse will assess the client receiving corticosteroids. The instillation of this medication does not carry any acute concerns that would warrant assessment prior to the other three clients.
The nurse is caring for a client with acute gout. The nurse reviews the client's medical history for what possible contributors to secondary gout? Select all that apply.
A decreased glomerular filtration rate Diagnosed with a hemolytic anemia Has been taking a cytotoxic medication Explanation: Secondary gout is not due to a defect in purine metabolism, but due to a secondary cause of hyperuricemia. The hyperuricemia may be caused by the increased breakdown of nucleic acids, as occurs with rapid cell breakdown, which occurs when taking cytotoxic medication or having hemolytic anemia. Other cases of secondary gout result from chronic renal disease with a decreased glomerular filtration rate. A family history of primary gout may place the client at increased risk for primary gout, but not secondary gout. The inability to process high purine foods would be a sign of primary gout, not secondary.
The nurse is assessing a client's risk for osteoarthritis. Which factor places the client at greatest risk for this condition?
Age Explanation: Age is the single greatest risk factor for development of osteoarthritis, in part because of the mechanical impact on joints over time. Other factors, such as obesity, injury, and heredity can also play a part, but age is the single greatest risk factor. Smoke exposure and social status are not identified risk factors for osteoarthritis.
The nurse is reviewing a laboratory report that documents the presence of HLA-B27 antigen. The nurse interprets this as being linked to which disorder?
Ankylosing spondylitis Explanation: The HLA-B27 antigen remains one of the best-known examples of an association between a disease and a hereditary marker; approximately 90 percent of those with ankylosing spondylitis possess the HLA-B27 antigen. Primary gout is often caused by an inborn error in metabolism and is characterized primarily by hyperuricemia and gout. Approximately 70 percent to 80 percent of those with the osteoarthritis syndrome have the rheumatoid factor (RF), an autoantibody that reacts with a fragment of immunoglobulin G (IgG) to form immune complexes.
A new client arrives at the clinic. The physician is suspecting the client may have systemic lupus erythematosus (SLE) given the clinical manifestations related to joint pain, skin changes, and history of pleural effusions. The nurse should anticipate which diagnostic test will be a priority to facilitate with the diagnosis?
Anti-DNA antibody test. Explanation: 95% 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 client has severe anemia but it is not specific for SLE. C-reactive protein will show an inflammatory response but again not specific for SLE.
When a nurse is caring for a client with systemic sclerosis (scleroderma), which condition does the nurse instruct the client causes symptoms of the disease?
Deposits of collagen in the skin and organs Explanation: Systemic sclerosis, or scleroderma, is an autoimmune disease of connective tissue characterized by excessive collagen deposits in the skin and internal organs such as the lungs, gastrointestinal tract, heart, and kidneys.
When caring for a client with psoriatic arthritis, the nurse assesses for which altered laboratory studies frequently associated with this disease?
Elevated uric acid level Explanation: The abnormally elevated serum uric acid level in clients with seronegative psoriatic arthritis is caused by the rapid skin turnover of psoriasis and the subsequent breakdown of nucleic acid, followed by its metabolism to uric acid.
The nurse is caring for a client with rheumatoid arthritis (RA). Which assessment findings correlate with this diagnosis? Select all that apply.
Fatigue Weight loss Anorexia Explanation: RA is characterized by weight loss, generalized aching, anorexia, fatigue, as well as joint changes such as pain and stiffness. Increased appetite and flushed skin are not symptoms of RA.
Which statement best describes the pathogenesis of systemic lupus erythematosus (SLE)?
Formation of autoantibodies and immune complexes (type III hypersensitivity) Explanation: SLE is characterized by the formation of autoantibodies and immune complexes (B-cell-hyperreactivity). SLE may be acute or insidious, and the course of the disease is characterized by exacerbations and remissions. Exposure to UV light, specifically UVB associated with exposure to the sun or unshielded fluorescent bulbs, may trigger exacerbations.
When caring for a client with ankylosing spondylitis, the nurse tells the client that stiffness may be relieved by which intervention?
Gentle exercise Explanation: The pain of ankylosing spondylitis becomes worse when resting, particularly when lying in bed, and may be relieved with physical activity. Lumbosacral pain may also be present, with discomfort in the buttocks and hip areas. Prolonged stiffness is present in the morning and after periods of rest. Mild physical activity or a hot shower helps reduce pain and stiffness.
A 16-year-old boy has been diagnosed with ankylosing spondylitis. Which etiology is responsible for his health problem?
Immune response Explanation: 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 30-year-old client has been diagnosed with ankylosing spondylitis. Which etiology is responsible for this health problem?
Immune response Explanation: Ankylosing spondylitis is thought to have an etiology that suggests an immune response. Physical wear and tear, infection, and inappropriate remodeling are not considered to be primarily responsible for the disease.
In general, how are children affected by a rheumatic disease such as juvenile idiopathic arthritis (JIA)?
It's characterized by synovitis and can influence epiphyseal growth, resulting in stunted growth. Explanation: Children can be affected by almost all of the rheumatic diseases that occur in adults. JIA is characterized by synovitis and can influence epiphyseal growth resulting in stunted growth. JIA is not a single disease but rather a category of diseases. The symptoms of systemic JIA include daily intermittent high fever, which usually is accompanied by a rash, enlarged lymph nodes, spleen and liver, and elevated white blood cell count. Systemic lupus erythematosus in children may involve the cardiac system.
Which signs and symptoms should prompt a young woman's primary care provider to assess for systemic lupus erythematosus (SLE)?
Joint pain and proteinuria Explanation: Renal involvement occurs in approximately one half to two-thirds of persons with SLE, and arthralgia is a common early symptom of the disease. Nephrotic syndrome causes proteinuria with resultant edema in the legs and abdomen, and around the eyes. Although the manifestations of SLE are diffuse, these do not typically include alterations in hemostasis, gastrointestinal symptoms, dysmenorrhea, or miscarriage.
Which pathophysiologic phenomenon would be most indicative of ankylosing spondylitis?
Loss of motion in the spinal column and eventual kyphosis. Explanation: The characteristic trait of ankylosing spondylitis is progressive loss of spinal ROM and eventual kyphosis. Synovial joint involvement is not associated with the disease. A butterfly rash and multisystem involvement are associated with SLE. Decreased bone density does not normally accompany ankylosing spondylitis.
The nurse is assessing a client with ankylosing spondylitis (AS). What does the nurse expect to find?
Lower back pain Explanation: The client with AS has an inflammatory erosion of the sites where tendons and ligaments attach to bone. The disease progresses with bilateral involvement of the sacroiliac joints and produces lower back pain. Joint contractures, butterfly rash, and bruises are not characteristic of this disease.
The nurse is conducting a health promotion class on osteoarthritis (OA). Which statement should the nurse include?
Obesity is a strong risk factor for developing OA. Explanation: Obesity is a strong risk factor for OA of the knee in women, and a contributory biomechanical factor in the pathogenesis of the disease. Young men have a higher risk, but after middle age, women are more at risk for developing OA. The statements regarding heredity and diet are not true.
The client with a suspected diagnosis of osteoarthritis asks the health care provider, "How will this diagnosis be confirmed?" Which response is most appropriate?
Physical examination and x-ray studies Explanation: The diagnosis of osteoarthritis usually is determined by history and physical examination, x-ray studies, and laboratory findings that exclude other diseases. The other options would not identify the disease.
Which are potential causes of osteoarthritis? Select all that apply.
Rheumatoid arthritis Posttraumatic disorders Metabolic disorders Collagen disorders Explanation: Rheumatoid arthritis, posttraumatic disorders, metabolic disorders, and collagen disorders are all possible causes of osteoarthritis.
When working with a client with diffuse scleroderma who is exhibiting a 'stone face' expression, the nurse should consider which of these to be a priority nursing diagnosis for this client?
Risk for aspiration related to swallowing impairments. Explanation: 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 face" due to tightening of the facial skin with restricted motion of the mouth. Involvement of the esophagus leads to hypomotility and difficulty swallowing. The other NANDAs would be of lower priority given the assessment data presented.
When teaching a group of nursing students about rheumatic disorders, a nurse emphasizes which important differences when caring for the older adult?
Risk for falls Explanation: The pain, stiffness, and muscle weakness affect daily life, often threatening independence and quality of life. Symptoms of the rheumatic diseases can also have an indirect effect on and even threaten the duration of life for older adults. The weakness and gait disturbance that often accompany rheumatic diseases can contribute to the likelihood of falls and fractures.
A nurse is caring for a client with rheumatoid arthritis (RA). For which of these extra-articular manifestations does the nurse assess? Select all that apply.
Splenomegaly Lymphadenopathy Elevated erythrocyte sedimentation rate (ESR) Explanation: Although characteristically a joint disease (articular disease), RA can affect a number of other tissues; extra-articular involvement may include reports of fatigue, weakness, anorexia, weight loss, and low-grade fever when the disease is active. The ESR, which is commonly elevated during inflammatory processes, has been found to correlate with the amount of disease activity. Anemia may be present. Other organs involvement may include splenomegaly, lymphadenopathy, pleural effusion, pericarditis, or nephropathy. Swollen joints is the primary problem and not an extra-articular manifestation.
While reviewing the following diagnostic findings on a group of clients with joint complaints, which finding would be a priority for further investigation and possible medical intervention?
Synovial fluid aspiration indicates the presence of monosodium urate crystals. Explanation: 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.
The nurse is providing client education related to intra-articular corticosteroid injections. Which instruction should the nurse include?
The injections will be given only 3 to 4 times per year because they can increase joint destruction. Explanation: The client needs to be educated regarding the limited use of the injections and the risk of these injections causing additional joint destruction. The client should not be encouraged to run, but can participate in muscle-strengthening exercises. The statements regarding discomfort and daily administration are not correct.
A client presents to the orthopedic clinic for evaluation since the primary care provider thinks the client may have rheumatoid arthritis (RA). Which statement by the client correlates with the diagnosis of RA? Select all that apply.
"I'm having a hard time opening doors since it hurts so bad." "Look, I didn't button all my shirt buttons....it just hurts too much and look at the swelling in my hands." "Look how my hand is deformed. My doctor calls it hyperextension." Explanation: Rheumatoid arthritis (RA) joint involvement usually is symmetric and polyarticular. Pain with turning door knobs, opening jars, and buttoning shirts is commonly reported due to swelling of the wrists and small joints of the hand. Hyperextension of the PIP joint and partial flexion of the distal interphalangeal (DIP) joint is called a swan neck deformity. As the RA inflammatory process progresses, synovial cells and subsynovial tissues undergo reactive hyperplasia. With osteoarthritis (OA), joint changes result from the inflammation caused when the cartilage attempts to repair itself, creating osteophytes or spurs. Raynaud phenomenon (a vascular disorder characterized by reversible vasospasm of the arteries supplying the fingers) and telangiectasia (dilated skin capillaries) are characteristic of scleroderma.
A client sought care because of increasing pain and inflammation in the toe and ankle of one foot. Diagnostic testing has resulted in a diagnosis of gouty arthritis. When educating the client about the treatment and management of the disease, what should the nurse teach the client?
"Losing some weight and reducing your alcohol intake will likely be beneficial." Explanation: For many clients with gout, changes in lifestyle may be needed, such as maintenance of ideal weight, moderation in alcohol consumption, and avoidance of purine-rich foods. Weekly blood work is not necessary and NSAIDs are preferred to opioids for pain management. Physiotherapy is not a major treatment modality for gout.
The nurse is caring for a client diagnosed with osteoarthritis (OA). What does the nurse teach the client about the disease?
"OA is a disease of the weight-bearing joints." Explanation: OA is a slowly progressive destruction of articular cartilage of weight-bearing joints and fingers of older adults and the joints of younger people who have experienced trauma.
The nurse is teaching a client about osteoarthritis. The nurse corrects the client when the client makes which inaccurate statement?
"Older men are more likely to have osteoarthritis than older women." Explanation: By age 55, females are more frequently affected by osteoarthritis (OA) than men so the client stating men are at greater risk requires correction. The load bearing joints are most frequently affected and the pathogenesis is related to articular cartilage breakdown, so these statements are correct. The vast majority of clients affected by OA are over 75, making older age a primary risk factor.
Following a progressive onset of fatigue, aching, and joint stiffness over the last two years, a 69-year-old male has recently been diagnosed with rheumatoid arthritis (RA). Which teaching point should his primary care physician include during the office visit in which this diagnosis is communicated to the client?
"Steroids and anti-inflammatory drugs that I'll prescribe will likely bring some relief to your symptoms." Explanation: Current treatment guidelines for RA involve early and aggressive pharmacologic treatment, including NSAIDs and corticosteroids. Damage cannot be reversed, and while therapeutic exercise plays a role in treatment, rest is also important.
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 statement would her nurse want to correct or clarify?
"The worst part of this so far has been learning that there aren't any treatments for scleroderma." Explanation: While the cause of scleroderma remains unknown, supportive treatments that address symptoms do exist. Reynaud phenomenon is a very common accompaniment to the disease; cardiac and pulmonary involvement are common.
A client presents with arthralgia and arthritis. Which is the priority nursing intervention?
Assessing the client's pain and history of treating it Explanation: When a client presents with joint pain and arthritis, this could be a symptom of several different disorders. The priority intervention is to assess the pain and assess the client's history of treating it. Vital signs and electrocardiogram might be appropriate further assessments. Range-of-motion exercises are not appropriate until the client is assessed.
The nurse is caring for a client with advanced ankylosing spondylitis (AS). What does the nurse include in the plan of care? Select all that apply.
Assessment of eyes for pain and inflammation. Assessment of dyspnea and respiratory function. Assist with ambulation due to increased risk for falls. Explanation: The client with AS experiences stiffness that is worse in the morning and after periods of rest; thus, the nurse would not plan for physiotherapy in early morning. In progressed disease, the development of a kyphotic spine makes it difficult for the client to look ahead and to maintain balance while walking, increasing the risk for falls. There is a constriction of the chest cavity that reduces lung capacity and may lead to respiratory symptoms or complications. Positioning is important and the client should sleep in a supine position on a firm mattress, using one small pillow or no pillow and not placed at 45 degrees. A common extraskeletal manifestation is acute anterior uveitis that manifests as pain, redness, and photophobia.
A nurse is caring for a client who has systemic lupus erythematosus (SLE). Which of the following causes the disease?
Autoimmune process Explanation: The cause of SLE is unknown. It is characterized by the formation of autoantibodies and immune complexes.
When teaching a client with rheumatoid arthritis (RA), which factor does the nurse explain is an underlying cause of this disease?
Autologous antibodies Explanation: The pathogenesis of RA can be viewed as an aberrant immune response that leads to synovial inflammation and destruction of the joint architecture. Approximately 70%-80% of people with the disease have a substance called rheumatoid factor, which is an autologous (self-produced) antibody that causes joint destruction.
A client who has recently been diagnosed with polymyositis asks the nurse how this problem arose. The nurse tells the client that the underlying cause of this disorder is:
Inflammation and immune mechanisms Explanation: Polymyositis is a chronic inflammatory myopathy. The pathogenesis is multifactorial and includes cellular and humoral immune mechanisms.
When explaining to the client diagnosed with gout how the xanthine oxidase inhibitors work, the health care provider would include which statement?
Blocks the production of uric acid by the body Explanation: Xanthine oxidase inhibitors block the synthesis of uric acid. In this classification, the most commonly prescribed to lower urate levels is allopurinol. The uricosuric agents prevent the tubular reabsorption of urate and increase its excretion in the urine. Uricase agents convert insoluble uric acid to a soluble product than can be excreted easily. Pegloticase is an infusible uricase agent that works rapidly to reduce serum uric acid.
Juvenile dermatomyositis is a chronic inflammatory myopathy that commonly manifests systemically. What is the treatment of choice for this myopathy?
Corticosteroids Explanation: Corticosteroids are the mainstay of treatment for these conditions. The other drug types are not the treatment of choice for polymyositis and dermatomyositis.
The nurse performing a musculoskeletal assessment of a client with osteoarthritis would evaluate the presence of which finding as being a normal expectation?
Crepitus and grinding Explanation: In osteoarthritis (OA) syndrome, crepitus and grinding may be evident when the osteoarthritic joint is moved. OA joint enlargement results from new bone formation and the joint feels hard—in contrast to the soft, spongy feeling characteristic of the joint in rheumatoid arthritis (RA). The person with ankylosing spondylitis typically reports low back pain, which becomes worse when resting, particularly when lying in bed. Cartilage atrophy develops as the pain of OA limits movements, but is rapidly reversible with a gradual increase in activity; impact exercise during the period of remobilization can cause serious cartilage damage. Laboratory studies for OA usually are normal because the disorder is not a systemic disease.
A nurse is caring for a client with ankylosing spondylitis. For which associated symptom does the nurse assess?
Kyphosis Explanation: Loss of motion in the spinal column is characteristic of the disease. Loss of lumbar lordosis occurs as the disease progresses, followed by kyphosis of the thoracic spine and extension of the neck.
Which statement is true regarding the development of juvenile idiopathic arthritis?
Generalized stunted growth can occur. Explanation: Generalized stunted growth can occur as well as unilateral increased growth related to the influence on epiphyseal growth. It will not resolve in adulthood, and surgical intervention is not an option to eliminate the disease.
An older adult client has had mobility and independence significantly impaired by the progression of rheumatoid arthritis (RA). What is the primary pathophysiologic process that has contributed to this client's decline in health?
Immunologically mediated joint inflammation Explanation: The pathogenesis of RA can be viewed as an aberrant immune response that leads to synovial inflammation and destruction of the joint architecture. Paget disease is caused by abnormal bone resorption and remodeling, whereas collagen deposition underlies scleroderma. Osteoarthritis is believed to be initiated by mechanical injury and subsequent cytokine release.
A 55-year-old client has reported joint pain in the feet. Which laboratory result should prompt further testing to rule out primary gout?
Increased serum uric acid Explanation: Although hyperuricemia is not diagnostic of gout, it is suggestive and should prompt further assessment. Increases in CRP, polymorphonuclear leukocytes, and cortisol levels are not as closely associated with the body's response to gout.
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 phenomenon most likely underlies the woman's situation?
Loss of articular cartilage and synovitis has resulted from inflammation caused when joint cartilage attempted to repair itself. Explanation: The joint changes associated with osteoarthritis, which include a progressive loss of articular cartilage and synovitis, results from the inflammation caused when cartilage attempts to repair itself, creating osteophytes or spurs. These changes are accompanied by joint pain, stiffness, limitation of motion, and in some cases by joint instability and deformity. Immune etiology is more associated with rheumatoid arthritis. Collagen deposits are characteristic of scleroderma. Bones do not tend to fuse in the pathogenesis of OA.
. Joint destruction in rheumatoid arthritis (RA) occurs by an obscure process. The cellular changes, however, have been documented. Place the process in the correct order.
Neutrophils, macrophages, and lymphocytes arrive . Immune complexes phagocytized Lysosomal enzymes released Destructive changes in joint cartilage Inflammatory response Reactive hyperplasia of synovial cells and subsynovial tissues Vasodilation Increased blood flow to joint Joint swelling
Joint destruction in rheumatoid arthritis occurs by an obscure process. The cellular changes, however, have been documented. Place the process in the correct order.
Neutrophils, macrophages, and lymphocytes arrive Immune complexes phagocytized, releasing lysosomal enzymes Destructive changes in joint cartilage Inflammatory response Reactive hyperplasia of synovial cells and subsynovial tissues Vasodilation and joint swelling Explanation: The role of the autoimmune process in the joint destruction of RA remains obscure. At the cellular level, neutrophils, macrophages, and lymphocytes are attracted to the area. The neutrophils and macrophages phagocytize the immune complexes and, in the process, release lysosomal enzymes capable of causing destructive changes in the joint cartilage. The inflammatory response that follows attracts additional inflammatory cells, setting into motion a chain of events that perpetuates the condition. As the inflammatory process progresses, the synovial cells and subsynovial tissues undergo reactive hyperplasia. Vasodilation and increased blood flow cause warmth and redness. The joint swelling that occurs is the result of the increased capillary permeability that accompanies the inflammatory process.
The nurse is caring for a client with newly diagnosed systemic lupus erythematosus (SLE). Which over-the-counter medication does the nurse recognize is useful in treating inflammation, arthritis, and pleuritis?
Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: Treatment with medications may be as simple as a drug to reduce inflammation, such as an NSAID. NSAIDs can control fever, arthritis, and mild pleuritis.
When a nurse is assessing a client with osteoarthritis, which factor poses a risk for the disease?
Obesity Explanation: Obesity is a particular risk factor for OA of the knee in women and a contributory biomechanical factor in the pathogenesis of the disease; OA is a problem occurring in weight-bearing joints.
A client presents with a "spur" on the joint. The client asks, "Why did this happen? I guess I just did not exercise enough." Which pathophysiologic mechanism of osteoarthritis (OA) should the nurse explain to this client?
Osteophyte formation and erosion of cartilage Explanation: As OA progresses, cartilage is lost and osteophytes, or spurs, develop on the surface of the articulating bones. Osteonecrosis does not typically develop, and synovial fluid is not lost. Tophi are associated with gout, not OA. The epiphyseal plate does not separate in the course of OA.
A client with rheumatoid arthritis has been taking a combination of disease-modifying antirheumatic drugs (DMARDs), which are a variety of immunosuppressants and immunomodulators, for years. Which laboratory result(s) indicate the client may be experiencing toxic adverse effects and will need the medications adjusted? Select all that apply.
Platelet count 10,000/µL (100 ×109/L) Red blood cell count of 8.0 ×106/µL (8.0 ×1012/L) Absolute neutrophil count of 500/µL (0.50 ×109/L) Explanation: Bone marrow suppression, also known as myelosuppression, is the decrease in production of cells responsible for providing immunity (leukocytes), carrying oxygen (erythrocytes), and/or those responsible for normal blood clotting (thrombocytes). Anemia occurs when red blood cells are low. Leukopenia/neutropenia happens when the white blood cells are low. White blood cells help your body fight off diseases. Leukopenia does not cause many noticeable side effects, but it means the person will be at higher risk of developing an infection. Thrombocytopenia is when your platelet count is low. A normal platelet count ranges from 150,000/μL to 400,000/μL (1500 to 4000 ×109/L) ; below 10,000/μL (100 ×109/L) is a severely low count. With this disorder, one will likely notice bruising easier, bleeding easier, having tiny red spots on the skin, or having blood in the urine. Normal adult red blood cell count is between 12 to 14 g/dL . Below that is low and called anemia. Neutropenia is an abnormally low concentration of neutrophils (a type of white blood cell) in the blood. Normal serum potassium levels are between 3.5 and 5.0 mEq/L (3.5 and 5.0 mmol/L). Normal adult creatinine levels (which indicates renal function) is 0.6 to 1.2 mg/dL (53-106 µmol/L).
Which type of joint manifestations would the nurse anticipate finding in a client with rheumatoid arthritis?
Polyarticular Explanation: Rheumatoid arthritis (RA) joint involvement usually is symmetric and polyarticular. In the hands, there usually is bilateral and symmetric involvement of the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints in the early stages of RA. As the RA inflammatory process progresses, synovial cells and subsynovial tissues undergo reactive hyperplasia. With osteoarthritis (OA), joint changes result from the inflammation caused when cartilage attempts to repair itself, creating osteophytes or spurs.
Giant cell arteritis is a comorbid condition of:
Polymyalgia rheumatica Explanation: A certain percentage of people with polymyalgia rheumatica also develop giant cell arteritis (i.e., temporal arteritis) with involvement of the ophthalmic arteries. This is not an associated outcome of any of the other options.
An older adult reports waking up in the morning with pain/stiffness in the neck/shoulders. Laboratory work reveals an elevated erythrocyte sedimentation rate (ESR). Following a short trial of prednisone with significant improvement, the health care provider likely will diagnose which disorder?
Polymyalgia rheumatica Explanation: Polymyalgia rheumatica is a common syndrome of older clients, rarely occurring before 50 years of age and usually after 60 years of age. It is an inflammatory condition characterized by aching and morning stiffness in the shoulder and pelvic areas. The diagnosis is confirmed when the symptoms respond dramatically to a small dose of prednisone, a corticosteroid. For symptomatic people with an elevated ESR, the person is given oral steroids. Reiter syndrome, psoriatic arthritis, and ankylosing spondylitis may occur at younger ages.
A client diagnosed with arthritis had a recent infection. Which intervention is necessary to determine if the client has bacterial arthritis?
Positive culture of synovial fluid Explanation: Bacterial arthritis is confirmed when bacteria are cultured from the synovial fluid of the joints. The other interventions are not used to diagnose bacterial arthritis.
A client returns to the clinic for review of previous laboratory values. A diagnose of ankylosing spondylitis (AS) is made, based on laboratory results and manifestations of low back pain which worsens when resting, thigh pain like that of sciatica, and morning stiffness. Which educational teaching would be appropriate for the nurse to provide? Select all that apply.
Proper posture Use of firm mattress with one small pillow Muscle-strengthening exercises for extensor muscle group Explanation: Treatment of AS is directed at pain control and maintaining mobility by suppressing inflammation. Proper posture and positioning are important. This includes sleeping in supine position on a firm mattress and using one small pillow. Muscle-strengthening exercises for extensor muscle group also are prescribed. Immobilizing of joints is not recommended. Although DMARDs are used in the treatment of other inflammatory illnesses, they have not been shown to be effective for axial ankylosing spondylitis; with the exception of sulfasalazine for peripheral joint involvement.
A client has been diagnosed with scleroderma. Which assessment finding does the nurse expect?
Raynaud phenomenon Explanation: Scleroderma presents with multiple clinical symptoms. Raynaud phenomenon is generally associated with the disorder. Facial rash, increased blood pressure, and cardiac dysrhythmias are not classic symptoms. The acronym CREST is typically used to remember symptoms: calcinosis, Raynaud's, esophageal dysmotility, sclerodactyly, and telangiectasias. In addition, autoantibodies, pulmonary fibrosis, and contraction of digital joints can be found.
The nurse assessing a client with scleroderma with CREST variant would include an assessment for:
Raynaud's phenomenon. Explanation: Raynaud's phenomenon is the characteristic symptom of CREST variant of scleroderma that is identified by the R in the CREST acronym. The other options are associated with systemic lupus erythematosus.
A client reports increasing pain at the back of the ankle over the past 2 weeks. The client states being generally healthy, despite having just completed a course of antibiotics for an infection 6 weeks prior for Chlamydia trachomatis. This client is likely experiencing which type of reaction?
Reactive arthritis Explanation: Reactive arthritis may be triggered by infections such as that caused by Chlamydia trachomatis. The Achilles tendon and plantar fascia are the most common sites of involvement, and this is nearly always accompanied by pain. Osteoarthritis, systemic sclerosis, and ankylosing spondylitis are not suggested by this specific chain of events.
The health care provider is assessing a client with a history of ankylosing spondylitis to note progression of the disease. On which area of the body will the provider focus the assessment?
Spine Explanation: Ankylosing spondylitis affects the axial skeleton and manifests by pain and progressive stiffening of the spine. Occasionally, large synovial joints (i.e., hips, knees, and shoulders) may be involved. The other areas would not be affected.
A nurse is caring for a client admitted with a malar rash on the nose and cheeks. The nurse recognizes that this rash is characteristic of which disease process?
Systemic lupus erythematosus (SLE) Explanation: In SLE, the acute skin lesions include the classic malar or "butterfly" rash on the nose and cheeks.
A 68-year-old woman has had her mobility and quality of life severely affected by rheumatoid arthritis (RA). Place the following pathophysiologic events involved in her health problem in the correct order that they most likely occurred. Use all the options.
T-cell mediated immune response Interaction between rheumatoid factor (RF) and IgG Inflammatory response Pannus invasion Destruction of articular cartilage
The physician is considering prescribing an anti-tumor necrosis factor (TNF) like infliximab for a client with rheumatoid arthritis (RA). Which statement is accurate about the advantages of using a TNF inhibitor?
TNF inhibitors help slow the disease progression and improve your ability to perform routine ADL functions. Explanation: 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-α, one of the key proinflammatory cytokines in RA. Anti-TNF-α agents have 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 TNK inhibitor agents also have been show to inhibit radiologic disease progression and improve functional outcomes.
Though 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?
The woman complains of aching and morning stiffness in her neck, shoulder and pelvis. Explanation: 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.
A nurse is caring for a client who has developed vasculitis as a result of a rheumatology disorder. Which factor does the nurse expect to uncover in assessing this client?
Ulcers of the lower extremities Explanation: Vasculitis, or inflammation of small and medium-sized arteries, manifests as ischemic areas in the nail fold and digital pulp that appear as brown spots. Ulcerations may occur in the lower extremities, particularly around the malleolar areas.
When teaching a client recently diagnosed with systemic lupus erythematosus (SLE), what does the nurse teach the client to avoid to prevent exacerbations?
Ultraviolet light (UV) Explanation: Possible environmental triggers for SLE include UV light, chemicals (e.g., drugs, hair dyes), some foods, and infectious agents. Sun exposure may trigger exacerbations.
When a nurse is caring for a client with gout, which diagnostic study supporting the presence of the disease does the nurse monitor?
Uric acid levels Explanation: People diagnosed with a gout disorder have a high uric acid level, greater than 6.8 mg/dL (404.5 μmol/L).
The nurse is teaching a client with rheumatoid arthritis about pannus, which develops in the affected joint area. What does the nurse include to describe pannus?
Vascular granulation tissue that destroys cartilage and bone Explanation: A network of new blood vessels in the synovial membrane that contributes to the advancement of the rheumatoid synovitis, called pannus, develops. This destructive vascular granulation tissue extends from the synovium to involve a region of unprotected bone at the junction between cartilage and the subchondral bone. Inflammatory cells found in the pannus have a destructive effect on adjacent cartilage and bone leading to reduced joint motion and the possibility of eventual ankylosis.
An older adult client has recently been diagnosed with rheumatoid arthritis. The nurse should focus assessment on which aspects?
Weight and nutritional status Explanation: Anorexia is a common extra-articular symptom of rheumatoid arthritis. Consequently, there is a need to monitor the client's nutritional status and intake. Cognition, respiratory status, and electrolytes are not typically affected.
Which diagnostic finding has been strongly linked to systematic lupus erythematosus (SLE)?
elevated anti-nuclear antibodies (ANA) Explanation: There is no single diagnostic test that is used to diagnose SLE, such as an "SLE assay." However, the most common laboratory test performed is the immunofluorescence test for ANA, because 95% of people eventually diagnosed with the disease have elevated ANA levels. Rheumatoid factor is relevant to the diagnosis of rheumatoid arthritis, but is not among the diagnostic criteria for SLE. SLE can cause anemia, characterized by a low RBC count, but this finding is not specific to SLE to the same degree as elevated ANA.
A client with osteoarthritis states that every morning "it gets harder and harder to loosen up". The client's main therapy to this point is the use of over-the-counter nonsteroidal anti-inflammatories (NSAIDs). These drugs reduce the client's pain by:
inhibiting prostaglandin synthesis. Explanation: The primary cause of discomfort in OA is rooted in inflammation. NSAIDs inhibit cyclooxygenase (COX)-mediated synthesis of prostaglandins, which have a damaging effect on joint structures. They do not interact with opioid receptors or promote cytokine release. NSAIDs tend to reduce blood flow at inflammation sites as part of their anti-inflammatory effect.
The nurse is teaching a client with systemic lupus erythematosus (SLE) about the typical treatment course with this condition. Place in order the typical classes of medication used from earliest stages to the latest stages of the disease. Use all options.
nonsteroidal anti-inflammatory drugs (NSAIDs) antimalarial drug (hydroxychloroquine) systemic corticosteroid drugs immunosuppressive medications Explanation: Treatment of SLE begins with the anti-inflammatory medications that pose the least side effects while symptoms are mild, such as an NSAID to control fever and arthritis. If this class fails to control symptoms, the antimalarial drug hydroxychloroquine is generally the next medication used. Once this medication fails to control symptoms, corticosteroids may be added to control the more significant symptoms. Sometimes high-dose corticosteroids may need to be used to control symptoms. Finally, immunosuppressive drugs such as cyclophosphamide are used in cases of severe disease.
A 56-year-old client has been dealing with chronic back pain throughout his entire life, but recently the pain has begun to involve the shoulder as well. The client has been subsequently diagnosed with a seronegative spondyloarthropathy. Which physiologic description encompasses the disease involvement?
the axial skeleton and an abnormal autoimmune response Explanation: Seronegative spondyloarthropathies are arthritic disorders characterized by involvement of the axial skeleton and an abnormal autoimmune reaction. They do not result from wear and tear, connective tissue degeneration, or the accumulation of uric acid.
