Rheumatoid

10. A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate? A. "Your family may need some help to understand the impact of your rheumatoid arthritis." B. "You may need to see a family therapist for some help." C. "Perhaps it would be helpful for you and your family to get involved in a support group." D. "Tell me more about the situations that are causing stress."

10. Answer: D Rationale: The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

11. The health care provider plans to prescribe methotrexate (Rheumatrex) to a patient with newly diagnosed rheumatoid arthritis (RA). The patient tells the nurse, "That drug has too many side effects; I would rather wait until my joint problems are worse before beginning any drugs." The most appropriate response by the nurse is: A. "You should tell the doctor how you feel so the two of you can make a decision together." B. "It is important to start methotrexate early in order to decrease the joint damage." C. "Methotrexate is not expensive and will be cheaper to take than other possible drugs." D. "Methotrexate is very effective and has no more side effects than the other available drugs."

11. Answer: B Rationale: Disease-modifying anti-rheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

12. A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing a side effect of the medication? A. The patient has experienced a recent 5-pound weight loss. B. The patient's erythrocyte sedimentation rate (ESR) has increased. C. The patient's blood glucose is 166 mg/dl. D. The patient has no improvement in symptoms

12. Answer: C Rationale: Hyperglycemia is a side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication.

13. The home health nurse is doing a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed? A. The patient sleeps with two pillows under the head. B. The patient has been taking 16 aspirins daily. C. The patient requires a 2 hour midday nap. D. The patient sits on a stool when preparing meals.

13. Answer: A Rationale: The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective.

14. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for: A. Limited motion of joints. B. Deformed joints of the hands. C. Early morning stiffness. D. Rheumatoid nodules.

14. Answer: C Initially, most clients with early symptoms of rheumatoid arthritis complain of early morning stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules.

15. A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which nursing diagnosis would be most appropriate? A. Activity intolerance related to fatigue and pain. B. Self-care deficit related to increasing joint pain. C. Ineffective coping related to chronic pain. D. Disturbed body image related to fatigue and joint pain.

15. Answer: A Based on the client's complaints, the most appropriate nursing diagnosis would be Activity intolerance related to fatigue and pain. Nursing interventions would focus on helping the client conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the activity intolerance and increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may develop ineffective coping or body image disturbance as the disorder becomes chronic with increasing pain and fatigue.

16. Of the clients listed below, who is at risk for developing rheumatoid arthritis (RA)? Select all that apply. A. Adults between the ages of 20 and 50 years. B. Adults who have had an infectious disease with the Epstein-Barr virus. C. Adults that are of the male gender. D. Adults who possess the genetic link, specifically HLA-DR4. E. Adults who also have osteoarthritis.

16. Answer: A, B, D Rheumatoid arthritis (RA) affects women three times more often than men, between the ages of 20 and 55 years. Research has determined that RA occurs in clients who have had infectious disease, such as the Epstein-Barr virus. The genetic link, specifically HLA-DR4, has been found in 65% of clients with RA. People with osteoarthritis are not necessarily at risk for developing rheumatoid arthritis.

17. A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care? A. Relieving pain. B. Preserving joint function. C. Maintaining usual ways of accomplishing tasks. D. Preventing joint deformity.

17. Answer: C Maintaining usual ways of accomplishing tasks would be the lowest priority during the acute phase. Rather, the focus is on developing less stressful ways of accomplishing routine tasks. Pain relief is a high priority during the acute phase because pain is typically severe and interferes with the client's ability to function. Preserving joint function and preventing joint deformity are high priorities during the acute phase to promote an optimal level of functioning and reduce the risk of contractures.

18. The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit? A. "I can use heat and cold as often as I want." B. "With heat, I should apply it for no longer than 20 minutes at a time." C. "Heat-producing liniments can be used with other heat devices." D. "Ten to 15 minutes per application is the maximum time for cold applications."

18. Answer: C Heat-producing liniment can produce a burn if used with other heat devices that could intensify the heat reaction. Heat and cold can be used as often as the client desires. However, each application of heat should not exceed 20 minutes, and each application of cold should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat, and vasodilation instead of vasoconstriction with cold.

19. The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?" Which of the following responses by the nurse would be most appropriate? A. "It's the physician's prerogative to decide how to treat you. The physician has chosen what is best for your situation." B. "Tell me more about your friend's arthritic condition. Maybe I can answer that question for you." C. "That drug is used for cases that are worse than yours. It wouldn't help you, so don't worry about it." D. "Every person is different. What works for one client may not always be effective for another."

19. Answer: D The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the physician's prerogative to decide how to treat the client implies that the client is not a member of his or her own health care team and is not a participant in his or her care. The statement also is defensive, which serves to block any further communication or questions from the client about the physician. Asking the client to tell more about the friend presumes that the client knows correct and complete information, which is not a valid assumption to make. The nurse does not know about the client's friend and should not make statements about another client's condition. Stating that the drug is for cases that are worse than the client's demonstrates that the nurse is making assumptions that are not necessarily valid or appropriate. Also, telling the client not to worry ignores the underlying emotions associated with the question, totally discounting the client's feelings.

22. After teaching the client with severe rheumatoid arthritis about prescribed methotrexate (Rheumatrex), which of the following statements indicates the need for further teaching? A. "I will take my vitamins while I'm on this drug." B. "I must not drink any alcohol while I'm taking this drug." C. "I should brush my teeth after every meal." D. "I will continue taking my birth control pills."

22. Answer: A Because some over-the-counter vitamin supplements contain folic acid, the client should avoid self-medication with vitamins while taking methotrexate, a folic acid antagonist. Because methotrexate is hepatotoxic, the client should avoid the intake of alcohol, which could increase the risk for hepatotoxicity. Methotrexate can cause bone marrow depression, placing the client at risk for infection. Therefore, meticulous mouth care is essential to minimize the risk of infection. Contraception should be used during methotrexate therapy and for 8 weeks after the therapy has been discontinued because of its effect on mitosis. Methotrexate is considered teratogenic.

24. A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate? A. "You are probably exercising too much. Decrease your exercise to every other day." B. "Tell the physician about your symptoms. Maybe your analgesic medication can be increased." C. "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." D. "Take a warm tub bath or shower before exercising. This may help with your discomfort."

24. Answer: D Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.

27. Laboratory findings that the nurse would expect to be present in the patient with RA include: A. Polycythemia B. Increased IgG C. Decreased WBC D. Increased C-reactive protein (CRP)

27. Answer: D Increased C-reactive protein (CRP)

28. A 70-year old patient is being evaluated for symptoms of RA. The nurse recognizes that a major problem in the management of RA in the older adult is that: A. RA is usually more severe in older adults B. Older patients are not as likely to comply with treatment regimens C. Drug interactions and toxicity are more likely to occur with multidrug therapy D. Laboratory and other diagnostic tests are not effective in identifying RA in older adults

28. Answer: C Drug interactions and toxicity are more likely to occur with multidrug therapy

29. After teaching a patient with RA about the prescribed therapeutic regimen, the nurse determines that further instruction is needed when the patient says: A. It is important for me to perform my prescribed exercises every day B. I should perform most of my daily chores in the morning when my energy level is highest C. An ice pack to a joint for 10 minutes may help relieve pain and inflammation when I have an acute flare D. I can use assistive devices such as padded utensils, electric can openers, and elevated toilet seats to protect my joints

29. Answer: B I should perform most of my daily chores in the morning when my energy level is highest

32. The nurse teaches the patient with RA that one of the most effective methods of aerobic exercise is: A. Ballet dancing B. Casual walking C. Aquatic exercises D. Low-impact aerobic exercises

32. Answer: C Aquatic exercises

33. In assessing the joints of a patient with rheumatoid arthritis, the nurse understands that the joints are damaged by (select all that apply). A. Bony ankylosis following inflammation of the joints B. The deterioration of cartilage by proteolytic enzymes C. The development of Heberden's nodes in the joint capsule D. Increased cartilage and bony growth at the joint margins E. Invasion of pannus into the joint causing a loss of cartilage

33. Answers: A, E Rationale: Bony ankylosis is the union of the bones of a joint by proliferation of bone cells, resulting in complete immobility. Bony ankylosis occurs with advanced rheumatoid arthritis. Joint changes from chronic inflammation begin when the hypertrophied synovial membrane invades the surrounding cartilage, ligaments, tendons, and joint capsule. Pannus (i.e., highly vascular granulation tissue) forms within the joint. It eventually covers and erodes the entire surface of the articular cartilage. The production of inflammatory cytokines at the pannus-cartilage junction further contributes to cartilage destruction. The pannus scars and shortens supporting structures such as tendons and ligaments, ultimately causing joint laxity, subluxation, and contracture.

9. The biologic agent anakinra (Kineret) is prescribed for a patient who has moderately severe rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about: A. Symptoms of gastrointestinal (GI) irritation or bleeding. B. Self-administration of subcutaneous injections. C. Taking the medication with at least 8 oz of fluid. D. Avoiding concurrently taking aspirin or NSAIDs.

9. Answer: B Rationale: Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or NSAIDs and these should not be discontinued.

31. After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when the patient says: A. Heat treatments should not be used if muscle spasms are present B. Cold applications can be applied for 15-20 minutes to relieve joint stiffness C. I should use heat applications for 20 minutes to relieve the symptoms of an acute flare D. When my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain

31. Answer: D When my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain

1. The health care provider prescribes methotrexate (Rheumatrex) for a 28-year-old woman with stage II moderate rheumatoid arthritis (RA). When obtaining a health history from the patient, the most important information for the nurse to communicate to the health care provider is that the patient has: A. A history of infectious mononucleosis as a teenager. B. A family history of age-related macular degeneration of the retina. C. Been trying to have a baby before her disease becomes more severe. D. Been using large doses of vitamins and health foods to treat the RA.

1. Answer: C Rationale: Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

25. The basic pathophysiologic process of rheumatoid arthritis (RA) is: A. Destruction of joint cartilage and bones by an autoimmune process B. Initiated by a viral infection that destroys the synovial membranes of joints C. The presence of HLA-DR4 antigen that causes inflammatory responses throughout the body D. An immune response that activates complement and produces inflammation of joints and other organ systems

25. Answer: D An immune response that activates complement and produces inflammation of joints and other organ systems.

26. During the physical assessment of the patient with moderate RA, the nurse would expect to find: A. Hepatomegaly B. Heberden's nodes C. Spindle-shaped fingers D. Crepitus on joint movement

26. Answer: C Spindle-shaped fingers

4. When teaching range-of-motion exercises to a patient who is having an acute exacerbation of rheumatoid arthritis (RA) with joint pain and swelling in both hands, the nurse teaches the patient that: A. Affected joints should not be exercised when pain is present. B. Cold applications before exercise will decrease joint pain. C. Exercises should be performed passively by someone other than the patient. D. Regular walking may substitute for range-of-motion (ROM) exercises on some days.

4. Answer: B Rationale: Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints as well as improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

2. A patient with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers, wrists, and feet with swelling, redness, and limited movement of the joints. When developing the plan of care, the nurse recognizes that the most appropriate patient outcome at this time is to: A. Maintain a positive self-image. B. Perform activities of daily living independently. C. Achieve satisfactory control of pain. D. Make a successful adjustment to disease progression.

2. Answer: C Rationale: The focus during an acute exacerbation of RA is to manage pain effectively. The other outcomes are appropriate long-term outcomes.

20. The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods? A. Proper body alignment. B. Elevating the part. C. Prone lying positions. D. Positions of flexion

20. Answer: D Positions of flexion should be avoided to prevent loss of functional ability of affected joints. Proper body alignment during rest periods is encouraged to maintain correct muscle and joint placement. Lying in the prone position is encouraged to avoid further curvature of the spine and internal rotation of the shoulders.

21. After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which of the following, if stated by the client, would indicate the need for additional teaching? A. Pushing with palms when rising from a chair. B. Holding packages close to the body. C. Sliding objects. D. Carrying a laundry basket with clinched fingers and fists.

21. Answer: D Carrying a laundry basket with clinched fingers and fists is not an example of conserving energy of small joints. The laundry basket should be held with both hands opened as wide as possible and with outstretched arms so that pressure is not placed on the small joints of the fingers. When rising from a chair, the palms should be used instead of the fingers so as to distribute weight over the larger area of the palms. Holding packages close to the body provides greater support to the shoulder, elbow, and wrist joints because muscles of the arms and hands are used to stabilize the weight against the body. This decreases the stress and weight or pull on small joints such as the fingers. Objects can be slid with the palm of the hand, which distributes weight over the larger area of the palms instead of stressing the small joints of the fingers to pick up the weight of the object to move it to another place.

23. A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following? A. Development of a cataract. B. Possible retinal degeneration. C. Part of the disease process. D. A coincidental occurrence.

23. Answer: B Difficulty seeing out of one eye, when evaluated in conjunction with the client's medication therapy regimen, leads to the suspicion of possible retinal degeneration. The possibility of an irreversible retinal degeneration caused by deposits of hydroxychloroquine (Plaquenil) in the layers of the retina requires an ophthalmologic examination before therapy is begun and at 6-month intervals. Although cataracts may develop in young adults, they are less likely, and damage from the hydroxychloroquine is the most obvious at-risk factor. Eyesight is not affected by the disease process of rheumatoid arthritis.

3. A home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes and a dry mouth. Which action by the nurse is most appropriate? A. Have the patient withhold the daily methotrexate (Rheumatrex) until talking with the health care provider. B. Reassure the patient that dry eyes and mouth are very common with RA. C. Teach the patient to use an antiseptic mouth wash tid. D. Suggest that the patient start using over-the-counter (OTC) artificial tears.

3. Answer: D Rationale: The patient's dry eyes and oral mucous membranes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes and mouth are not side effects of methotrexate. Although dry eyes and mouth are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. Rinsing the mouth to decrease oral dryness is appropriate, but the frequent use of antiseptic mouthwashes is not appropriate unless the patient has oral symptoms that require this.

30. A patient recovering from an acute exacerbation of RA tells the nurse she is too tired to bathe. The nurse should: A. Give the patient a bed bath to conserve her energy B. Allow the patient a rest period before showering with the nurses' help C. Tell the patient that she can skip bathing if she will walk in the hall later D. Inform the patient that it is important for her to maintain self-care activities

30. Answer: B Allow the patient a rest period before showering with the nurses' help

5. Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. When the patient has a follow-up visit 1 month later, the nurse recognizes that the patient's response to the treatment may be best evaluated by: A. Blood glucose testing. B. Liver function tests. C. Serum electrolyte levels. D. C-reactive protein level.

5. Answer: D Rationale: C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels will also be monitored to check for side effects of prednisone. Liver function is not routinely monitored for patients receiving steroids.

6. When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to: A. Stand rather than sit when performing household chores. B. Avoid activities that require continuous use of the same muscles. C. Strengthen small hand muscles by wringing sponges or washcloths. D. Protect the knee joints by sleeping with a small pillow under the knees.

6. Answer: B Rationale: Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee ROM.

7. When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex), which information is most important to communicate to the health care provider? A. The platelet count is 130,000/μl. B. The white blood cell count (WBC) is 1500/μl. C. The blood glucose is 130 mg/dl. D. The potassium is 5.2 mEq/L.

7. Answer: B Rationale: Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The other laboratory values are also abnormal but are not far from normal values and would not have any immediate serious consequences.

8. When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with: A. A warm bath followed by a short rest. B. A 10-minute routine of isometric exercises. C. Stretching exercises to relieve joint stiffness. D. Active range-of-motion (ROM) exercises.

8. Answer: A Rationale: Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.