Module 8-3: Exemplar: Rheumatoid Arthritis

A​ 16-year-old client presents with clinical manifestations of juvenile idiopathic arthritis​ (JIA). Which diagnostic test should the nurse anticipate being​ ordered?

- ESR ​Rationale: The diagnosis of JIA is identified based on a combination of diagnostic tests. Erythrocyte sedimentation rate​ (ESR) is a laboratory test that is used as an inflammatory marker for the diagnosis of arthritis. Urine​ cultures, coagulation​ tests, and electrolyte panels are not used for the diagnosis of JIA.

A client diagnosed with rheumatoid arthritis​ (RA) reports having trouble doing the prescribed physical therapy exercises because of stiffness. Which intervention should the nurse suggest to help the client follow the prescribed physical therapy​ program?

- "Try doing water aerobics at the gym" ​Rationale: Swimming or water aerobics is a good option for individuals with rheumatoid arthritis because the water supports the​ body, thus decreasing the amount of stress on the joints. Exercising for several hours each day at the​ gym, wearing lightweight clothing during​ exercise, or stopping exercising are not likely to increase mobility.

A client newly diagnosed with rheumatoid arthritis​ (RA) tells the​ nurse, "I understand that RA affects my joints. Does it have any other effects on my body that I should know​ about?" In​ response, which additional effect of RA should the nurse​ include?

- Anemia Rationale: RA often causes anemia that is resistant to iron therapy. It does not cause stomach​ ulcers, headaches, or liver failure.

A client diagnosed with rheumatoid arthritis​ (RA) states that the pain is controlled with NSAIDs. Which instruction related to the disease process and supportive care should the nurse​ provide? (Select all that​ apply.)

- Being aware of the adverse effects of prescribed medications - Taking NSAIDs at regular intervals with food or milk - Applying heat or cold to relieve pain - Exercising in the pool because it relieves pressure on the joints ​Rationale: The priorities of care for the client with rheumatoid arthritis are supportive care and education. Taking NSAIDs at regular intervals provides continued control of pain and discomfort. Taking NSAIDs with food or milk decreases the incidence of gastrointestinal upset. Clients should consume a​ well-balanced diet, use the application of heat and cold for​ pain, exercise in the pool because it supports the​ client's weight and relieves pressure on the​ joints, be aware of adverse effects of​ medications, lose weight if​ necessary, follow prescribed physical​ therapy, avoid​ smoking, and use​ muscle-strengthening exercises.

The nurse admits a client to the hospital who is suspected of having rheumatoid arthritis​ (RA). Which diagnostic test should the nurse expect to be ordered for the​ client? (Select all that​ apply.)

- C-reactive protein​ (CRP) - erythrocyte sedimentation rate​ (ESR) Rationale: Laboratory tests used to diagnose rheumatoid arthritis include​ C-reactive protein​ (CRP) levels and erythrocyte sedimentation rate​ (ESR), which are nonspecific inflammatory markers. The antinuclear antibody​ (ANA) test, renal function​ test, and kidney biopsy are diagnostic tests for systemic lupus​ erythematosus, not rheumatoid arthritis.

A client diagnosed with rheumatoid arthritis​ (RA) tells the​ nurse, "Because of my pain and​ fatigue, I can no longer take care of my family the way I used to. I feel like such a​ failure." Which intervention is appropriate for the nurse to implement for this​ client? (Select all that​ apply.)

- Encouraging the client to talk about changes brought about by the disease - Helping the client to identify strengths and what the client is still able to do for the family - Encouraging the client to make decisions about treatment Rationale: As the client becomes unable to fulfill normal familial​ roles, stress occurs in the family. Talking about the​ changes, identifying​ strengths, helping the client realize what they can still do for their​ family, and encouraging the client to continue to make medical decisions are important for maintaining a sense of​ self-control and​ self-esteem. It is not helpful to tell clients to put someone​ else's needs before their own. Encouraging the client to seek​ physician-centered care is also​ inappropriate, because​ client-centered care helps clients to decrease their dependence on healthcare services and ensures greater safety and efficacy of treatment.

Which independent nursing intervention should the nurse implement to treat a client diagnosed with rheumatoid arthritis​ (RA)? (Select all that​ apply.)

- Instructing the client to alternate periods of activity and rest - Teaching about​ low-impact aerobics - Promoting a​ well-balanced diet ​Rationale: Independent interventions for clients with rheumatoid arthritis include monitoring and treating chronic​ pain, preventing​ fatigue, addressing ineffective role​ performance, promoting a healthy body​ image, and providing support related to impaired mobility. Interventions for rheumatoid arthritis include teaching about​ low-impact aerobics, such as walking and​ swimming; alternating periods of activity and​ rest; and promoting a​ well-balanced diet. Arthrodesis is a surgical intervention used to fuse cervical​ vertebrae, wrists, and​ ankles; although it is a treatment for​ RA, it is not an independent nursing intervention. Avoiding sun exposure is an intervention for systemic lupus​ erythematosus, not rheumatoid arthritis.

A client with rheumatoid arthritis​ (RA) states,​ "My disease is normally well controlled with a regimen of medications and treatments.​ However, I'm experiencing a​ flare-up of the disease in the right​ knee." Which collaborative intervention should the nurse expect to​ implement?

- Intra-articular corticosteroid injections Rationale: Intra-articular corticosteroid injections are effective in treating local disease​ flare-ups without having to change the overall drug regimen. Sulfasalazine is used when the client is not responsive to other medications and is associated with toxic reactions. Hydroxychloroquine requires 3-6 months of therapy to see​ results; therefore, it is not useful in treating local​ flare-ups of the disease. Gold salts are better administered by​ injection; they are used for​ long-term treatment of​ RA, not for a local​ flare-up.

The nurse is caring for a client recently diagnosed with rheumatoid arthritis​ (RA). Which clinical manifestation found during the​ nurse's assessment supports the diagnosis of​ RA?

- Low grade fever Clients diagnosed with rheumatoid arthritis often have a​ low-grade fever. This finding supports the diagnosis of RA. Weight​ loss, morning stiffness that lasts more than 1​ hour, and fatigue are other symptoms that support this diagnosis.

The community health nurse is conducting a teaching session for community members on rheumatoid arthritis​ (RA). Which characteristic should the nurse list as being a risk factor for the development of​ RA? (Select all that​ apply.)

- Physiologic stressors - Genetic predisposition - Family history Rationale: Risk factors for RA include​ genetic, environmental,​ reproductive, and hormonal factors. Autoimmune disorders such as RA are more prevalent in​ women, not men. Diet is not a known risk factor in the development of RA.

The nurse is caring for a client who was recently diagnosed with rheumatoid arthritis​ (RA). Which treatment goal should the nurse assign to the​ client? (Select all that​ apply.)

- Preventing deformity - Reducing pain - Reducing inflammation - Preserving function ​Rationale: The treatment goals for clients with rheumatoid arthritis are to reduce​ pain, reduce​ inflammation, preserve​ function, and prevent deformity. There is no cure for rheumatoid arthritis.

A client with rheumatoid arthritis​ (RA) complains of pain and discomfort in the hands and knees. Which intervention should the nurse implement to reduce the pain and discomfort that the client is​ experiencing? (Select all that​ apply.)

- Providing a balanced diet - Administering prescribed corticosteroids - Administering prescribed NSAIDs - Providing periods of exercise ​Rationale: NSAIDs are used to treat inflammation and pain in clients with rheumatoid arthritis. Exercise increases muscle strength and preserves function.​ Low-dose corticosteroids are used to reduce pain and inflammation in clients with rheumatoid arthritis. These medications also slow the development and progression of bone erosion. Improving nutrition promotes a​ well-balanced diet enhancing overall health in clients. It is also recommended to substitute dietary fat with​ omega-3 fatty acids in fish oils. Some medications used to treat rheumatoid arthritis cause sun sensitivity. Clients are advised to decrease the amount of time in the sun and to use sunscreen with sun protection when outdoors.

The nurse instructs a client diagnosed with rheumatoid arthritis​ (RA) about the use of splints to reduce strain on joints. Which instruction is most important for the nurse to include in the​ teaching?

- Splints should be made of lightweight material Rationale: Splints should be made of lightweight materials that are easy to remove. Splints should be removed once or twice a day to perform​ range-of-motion (ROM) exercises. Night splints are often used on the hands and wrists. The best way to splint a hip is to lie prone for several hours on a firm bed.

The nurse is caring for a client diagnosed with rheumatoid arthritis​ (RA). Which client outcome leads the nurse to determine that treatment is​ successful? (Select all that​ apply.)

- The client maintains joint mobility. - The client has an active role in managing the disease. - The client uses stress management techniques to cope with the disease. - The client maintains a positive body image. Rationale: The client diagnosed with RA endures chronic pain. Pain medication should be taken regularly and prior to planned activities to remain​ pain-free. Positive outcomes include maintaining joint​ mobility, having an active role in managing the​ disease, maintaining a positive body​ image, and using stress management techniques to cope with the stress of the disease.

A client is admitted for uncontrolled pain caused by rheumatoid arthritis​ (RA). Which ongoing problem should the nurse assess in relation to the​ RA? (Select all that​ apply.)

- chronic​ pain - fatigue - poor​ self-esteem related to​ body-image issues - ineffective role performance ​Rationale: Ongoing problems related to RA include chronic​ pain, fatigue, poor​ self-esteem related to​ body-image issues, and ineffective role performance. Weight​ loss, not weight​ gain, is an issue for clients with RA.

Which nursing diagnosis is appropriate for the nurse to assign to a client diagnosed with rheumatoid arthritis​ (RA)?

- disturbed body image

The nurse assessing a client diagnosed with rheumatoid arthritis​ (RA) notes the presence of joint deformities. Which additional​ extra-articular manifestation of RA should the nurse look for in the​ client? (Select all that​ apply.)

- pericarditis - splenomegaly - subcutaneous nodules ​ Rationale: Rheumatoid arthritis has many systemic effects including subcutaneous​ nodules, pericarditis, and splenomegaly. These are the result of inflammation or high levels of circulating rheumatoid factors. RA does not cause hearing loss or hepatitis.

A client newly diagnosed with rheumatoid arthritis​ (RA) is prescribed therapy with a nonsteroidal​ anti-inflammatory agent​ (NSAID). Which side effect of the medication should the nurse list for the​ client? (Select all that​ apply.)

- stomach lining irritation - bleeding ulcers - nephrotoxicity ​ Rationale: The side effects of NSAIDs include stomach lining​ irritation, bleeding​ ulcers, and nephrotoxicity. An increased risk for infection is a side effect of immunosuppressive agents. Bone marrow depression is a side effect of gold salts.

The nurse is providing discharge teaching for a client diagnosed with rheumatoid arthritis​ (RA). Which client statement indicates to the nurse that further teaching is​ required?

- ​"I am so glad that this medication will cure my RA in a few​ weeks." - ​Rationale: Rheumatoid arthritis is a chronic disease that has no cure. Treatment is aimed at relieving​ pain, reducing​ inflammation, slowing joint​ damage, and improving the​ client's well-being. Physical therapy and​ range-of-motion exercises are often prescribed to improve​ mobility, and medications are given to reduce inflammation.

A client diagnosed with rheumatoid arthritis​ (RA) is scheduled for surgery to stabilize the​ client's cervical spine. For which type of surgery should the nurse expect to receive preoperative​ orders?

- ​Arthrodesis Rationale: An arthrodesis is a joint fusion surgery. It is performed to stabilize joints such as the cervical​ vertebrae, wrists, or ankles. A synovectomy is excision of the synovial membrane. It provides temporary relief of inflammation and pain. An arthroplasty is a total joint replacement that is performed in cases of gross deformity and joint destruction. A hysterectomy is the surgical removal of the uterus.