chapter 38 level 8 questions

Scleroderma typically begins with the involvement of which system?

Integumentary explanation: Scleroderma begins with skin involvement. The disease does not begin with respiratory, urinary, or cardiovascular involvement.

The nurse is constructing a teaching plan for the client newly diagnosed with scleroderma. What should the nurse include in the teaching plan?

Protect the hands and feet from the cold Explanation: Raynaud's phenomenon is associated with scleroderma. Client teaching must include strategies for protecting the feet and hands.

Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues?

Scleroderma Explanation: Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. SLE is an immunoregulatory disturbance that results in increased autoantibody production. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

The nurse is assessing a client who has had rheumatoid arthritis for several years. What clinical manifestation will the nurse expect to find in a client?

Small joint movement Explanation: Clinical manifestations of rheumatoid arthritis are usually bilateral and symmetrical and include small joint involvement and joint stiffness in the morning. Other systemic manifestations occur over time. Obesity, Bouchard's nodes, and asymmetric joint involvement can be seen with the early stage of the disease.

A client is prescribed a disease-modifying antirheumatic drug that is successful in the treatment of rheumatoid arthritis but has side effects, including retinal eye changes. What medication will the nurse anticipate educating the client about?

Hydroxychloroquine Explanation: The DMARD hydroxychloroquine is associated with visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. The nurse should emphasize the need for ophthalmologic examinations every 6-12 months. Azathioprine, diclofenac, and cyclophosphamide do not have visual changes as a side effect.

A client has had several diagnostic tests to determine if he has systemic lupus erythematosus (SLE). What result is very specific indicator of this diagnosis?

Positive Ati-dsDNA antibody test Explanation: Anti-double-stranded DNA (anti-dsDNA) antibody test is a test that shows high titers of antibodies against native DNA. This is very specific for SLE because this test is not positive for other autoimmune disorders. Anti-Smith (anti-Sm) antibodies are specific for SLE but are found in only 20% to 30% of clients with SLE. ANA titer shows the presence of an autoimmune disease but is not specific to SLE. The other lab studies may also indicate multisystem involvement.

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

-Dysphagia owing to hardening of the esophagus -Dyspnea owing to fibrotic cardiac tissue -Decreased ventilation owing to lung scarring Explanation: The changes within the body, although not visible directly, are vastly more important than the visible changes. The left ventricle of the heart is involved, resulting in heart failure. The esophagus hardens, interfering with swallowing. The lungs become scarred, impeding respiration. Digestive disturbances occur because of hardening (sclerosing) of the intestinal mucosa. Progressive kidney failure may occur.

A client with rheumatoid arthritis reports joint pain. What intervention is a priority to assist the client?

non steroidal anti-inflammatory drugs Explanation: Nonsteroidal anti-inflammatory drugs are the mainstay of treatment for rheumatoid arthritis pain. They help to decrease inflammation in the joints. Heat, rather than ice packs, is used to relieve pain. Paraffin baths may also help. Surgery is reserved for joint replacement when the joint is no longer functional; it is not an intervention specific to relieving pain.

The nurse is caring for a client who has been diagnosed with a "rheumatic disease." What nursing diagnoses will most likely apply to this client's care? Select all that apply.

-Alteration of self-concept -Fatigue -Pain Explanation: Clients with rheumatic diseases, which typically involve joints and muscles, experience problems with mobility, fatigue, and pain. Because of the limitations of the disease, clients often have an altered self-image and self-concept. Fluid and electrolyte imbalances are not typically associated with these types of diseases

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

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

A client comes to the emergency department complaining of pain in the right leg. When obtaining the history, the nurse learns that the client has a history of obesity and hypertension. Based on this information the nurse anticipates the client having which musculoskeletal disorder?

Degenerative joint disease Explanation: Obesity predisposes the client to degenerative joint disease. Obesity isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease.

Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)?

Disease-modifying anti-rheumatic drugs (DMARDs) Explanation: Once a diagnosis of RA has been made, treatment should begin with DMARDs. NSAIDs are used for pain and inflammation relief but must be used with caution in long-term chronic diseases due to the possibility of gastric ulcers. TNF blockers interfere with the action of tumor necrosis factor (TNF). Oral glucocorticoids, such as prednisone and prednisolone, are indicated for patients with generalized symptoms.

A client is complaining of severe pain in the left great toe. What lab studies that the nurse reviews indicate that the client may have gout?

Elevated uric acid levels Explanation: Gout is characterized by hyperuricemia (accumulation of uric acid in the blood) caused by alterations in uric acid production, excretion, or both. An elevated white blood count may be indicative of any inflammatory response and is not specific to gout. A decreased hemoglobin and hematocrit may indicate bleeding from somewhere in the body. Increased AST and ALT would indicate liver dysfunction.

A client with rheumatoid arthritis is prescribed a tumor necrosis factor (TNF)-alpha inhibitor. What medication might be prescribed?

Etanercept Explanation: Etanercept is an example of a tumor necrosis factor (TNF)-alpha inhibitor used to treat rheumatoid arthritis. Diclofenac and indomethacin are nonsteroidal anti-inflammatory drugs (NSAIDs). Celecoxib is a cyclooxygenase-2 (COX-2) inhibitor.

A client comes to the clinic and reports pain in the right great toe which is worse at night. Assessment reveals tophi. What does the nurse suspect?

Gouty arthritis Explanation: Gout results from the inability to metabolize purines. This condition is most commonly seen in men and usually affects the legs, feet, and knees. Osteoarthritis is caused by degeneration of the joints. Rheumatoid arthritis is a systemic disorder more common in women of childbearing age. Reactive arthritis is seen with infections and is most common in young adult males.

A client informs the nurse that he has been diagnosed with degenerative joint disease of the fingers but now has these bumps on his fingers that don't hurt. The nurse observes bony nodules on the distal interphalangeal joints. What type of "bumps" does the nurse understand these are?

Heberden's nodes Explanation: DJD affects the hands; the fingers frequently develop painless bony nodules on the dorsolateral surface of the interphalangeal joints. Heberden's nodes are bony enlargement of the distal interphalangeal joints. Bouchard's nodes are bony enlargement of the proximal interphalangeal joints. Rheumatoid nodules are associated with rheumatoid arthritis. Tophi occur with gout and elevated uric acid levels.

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

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

A client is diagnosed with systemic lupus erythematosus (SLE). What is the most appropriate action for the nurse to take in order to evaluate the client's stage of disease?

Review the client's medical record Explanation: The nurse evaluates the stage of SLE and plans appropriate interventions by reviewing the medical record and diagnostic findings of the client. The stage of the disease cannot be established by observing the client's gait, inspecting the client's mouth, or auscultating the client's lung sounds.

A client who has been diagnosed with osteoarthritis asks if he or she will eventually begin to notice deformities in the hands and fingers as the condition progresses. Which concept should the nurse include in the response?

hand and finger deformities are associated with the development of rheumatoid arthritis Explanation: The nurse should explain to the client that joint deformities occur with rheumatoid arthritis, not osteoarthritis. Osteoarthritis typically follows a pattern of cartilage destruction and increased pain. The nurse is part of the interdisciplinary health care team and is capable of answering the client's questions about the typical progression of disease.

A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to:

combat inflammation Explanation: Corticosteroids are used to combat inflammation in a child with SLE. To prevent infection, the physician would order antibiotics. Aspirin is used to prevent platelet aggregation. Diuretics, not corticosteroids, promote diuresis.

A client is admitted with an acute attack of gout. What interventions are essential for this client? Select all that apply.

-Dietary consult -Probenecid -Corticosteroid therapy -Pain medication -Serum uric acid concentration Explanation: Steroids may be used in clients who have not responded to other therapies. They have been shown to decrease inflammation and pain in attacks of gout. Probenecid will assist in the excretion of uric acid, the causative agent. Serum uric acid concentrations will guide therapy and treatment. A dietary consult can wait until the client the acute, painful period is over but will be a necessary nursing intervention for a client experiencing gout.

The nurse is working with a client with systemic lupus erythematosus (SLE). What are the immune abnormalities characterized by SLE? Select all that apply.

-susceptibility -abnormal innate and adaptive immune responses -autoantibodies immune complexes -inflammation -damage Explanation: The immune abnormalities that characterize SLE occur in five phases: susceptibility, abnormal innate and adaptive immune responses, autoantibodies immune complexes, inflammation, and damage.

Azathioprine (Imuran) has been prescribed for the client with severe rheumatoid arthritis. The dose prescribed is 2 mg/kg/day orally in two divided doses. The medication available is a 50-mg scored tablet. The client weighs 110 pounds. How many milligrams will the nurse prepare per dose for the client?

50 Explanation: the client weighs 50 kg (110 lbs/2.2 lbs per kg). The client will receive 100 milligrams per day (50 kg x 2 milligrams/kg). The medication is to be given in two divided doses or 50 mg per dose.

A client with an acute exacerbation of arthritis is temporarily confined to bed. What position will the nurse recommend preventing flexion deformities?

Prone Explanation: It is best for the client with rheumatoid arthritis to lie prone several times daily to prevent hip flexion contracture. Semi- Fowler's position, side-lying with pillows, and supine with pillows are positions that have hip flexion.

The nurse knows that a patient who presents with the symptom of "blanching of fingers on exposure to cold" would be assessed for what rheumatic disease?

Raynaud's phenomenon Explanation: Blanching of fingers on exposure to cold is associated with Raynaud's phenomenon.

The nurse is teaching the client newly diagnosed with systemic lupus erythematous about the condition. Which statement by the client indicates teaching was effective?

I should avoid prolonged exposure to the sun. Explanation: Prolonged exposure to sun and ultraviolet light can cause exacerbation and disease progression

A client is receiving treatment for an acute episode of gout with colchicine. The nurse is administering the medication every 2 hours. What should the nurse be sure the client communicates so that the drug can be temporarily stopped? Select all that apply.

-Diarrhea -Intestinal cramping -Nausea and vomiting Explanation: Colchicine is administered every 1 or 2 hours until the pain subsides or nausea, vomiting, intestinal cramping, and diarrhea develop. When one or more of these symptoms occurs, the drug should be stopped temporarily. Tingling in the arms and increase in pain are not normal adverse reactions that are seen with this drug.

The nursing assessment findings reveal joint swelling and tenderness in the great toe of a client. What does the nurse suspect?

Gout

A client arrives at the clinic with reports of pain in the left great toe. The nurse assesses a swollen, warm, erythematous left great toe. What disorder will the nurse relate the client symptoms to?

GoutExplanation:The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of patients) in gout. The abrupt onset often occurs at night, awakening the patient with severe pain, redness, swelling, and warmth of the affected joint. Clients with osteoarthritis and rheumatoid arthritis will have joint swelling and tenderness in the hands, knees and spine. Clients with fibromyalgia will have chronic fatigue, generalized muscle aching, stiffness, sleep disturbances, and functional impairment.

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

It will get better and worse again explanation: The client demonstrates understanding of rheumatoid arthritis if he expresses that it's an unpredictable disease characterized by periods of exacerbation and remission. There's no cure for rheumatoid arthritis, but symptoms can be managed. Surgery may be indicated in some cases.

The nurse is performing a health history with a new client with fibromyalgia. What will the nurse expect to assess as the most common finding associated with fibromyalgia?

Wide spread chronic pain Explanation: The most common finding associated with fibromyalgia is widespread and chronic pain. Heberden nodes are associated with osteoarthritis. Jaw locking is a manifestation of temporomandibular joint dislocation. A butterfly facial rash is associated with systemic lupus erythematosus.

A client is seen in the office for reports of joint pain, swelling, and a low-grade fever. What blood studies does the nurse know are consistent with a positive diagnosis of rheumatoid arthritis (RA)? Select all that apply.

-Red blood cell (RBC) count of <4.0 million/mcL -Positive antinuclear antibody (ANA) -Positive C-reactive protein (CRP) Explanation: Several assessment findings are associated with RA: rheumatoid nodules, joint inflammation detected on palpation, and laboratory findings. The history and physical examination focuses on manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tend to be significantly elevated in the acute phases of RA and are therefore useful in monitoring active disease and disease progression. The red blood cell count and C4 complement component are decreased. Antinuclear antibody (ANA) test results may also be positive.

A client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms, he doesn't need to take his medication any longer. What is the best response by the nurse?

It is important that you continue to take your medication to avoid an acute exacerbation. Explanation: Even with remission, most people must continue taking prescribed medications to avoid another acute exacerbation. The client should be encouraged to maintain the therapeutic regimen in order to avoid an exacerbation and prolong the period of remission as long as possible. If the client is considering the discontinuation of the medication, he should notify the physician prior. The nurse is not at liberty to allow the client to discontinue medication use. Informing the client he will become ill if he discontinues the medication does not inform them of the rationale.

A nurse is assigned to a client with polymyositis. Which expected outcome in the care plan relates to a potential problem associated with polymyositis?

Client will exhibit no signs or symptoms of aspiration Explanation: An expected outcome of no signs or symptoms of aspiration relates to symmetrical muscle weakness — a potential problem associated with polymyositis that may lead to speaking and swallowing problems. A client with a potential swallowing problem is at risk for inadequate nutrition and shouldn't be placed on a calorie-restricted diet; an expected outcome focusing on maintaining weight would be more appropriate than an outcome based on losing weight. Polymyositis doesn't affect bowel or bladder function or mental status; it isn't necessary to develop outcomes based on these parameters.

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

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

the side effect of bone marrow depression may occur with which medication used to treat gout?

Allopurinol Explanation: A client taking allopurinol needs to be monitored for the side effects of bone marrow depression, vomiting, and abdominal pain.

A health care provider orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis?

An above normal anti-deoxyribonucleic acid(DNA)test Explanation: Laboratory results specific for SLE include an above-normal anti- DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE.

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

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

A client with a history of peptic ulcer disease is diagnosed with rheumatoid arthritis. What medication will the nurse anticipate will be prescribed to produce an anti-inflammatory effect and protect the stomach lining?

Celecoxib Explanation: The cyclooxygenase-2 inhibitors, such as celecoxib, have been shown to inhibit inflammatory processes but do not inhibit the protective prostaglandin synthesis in the gastrointestinal (GI) tract. Therefore, patients who are at increased risk for gastrointestinal complications, especially GI bleeding, have been managed effectively with celecoxib. Ibuprofen, methotrexate, and sulfasalazine may cause GI irritation.

A client has a history of osteoarthritis. Which signs and symptoms should the nurse expect to find on physical assessment?

Joint pain, crepitus, Heberden's nodes Explanation: Clinical findings for osteoarthritis include joint pain, crepitus, Heberden's nodes (bony growths at the distal interphalangeal joints), Bouchard's nodes (growths involving the proximal interphalangeal joints) and enlarged joints. The joint pain occurs with movement and is relieved by rest. As the disease progresses, pain may also occur at rest. Bouchard's nodes involve the proximal interphalangeal joints. Hot, inflamed joints rarely occur in osteoarthritis. Tophi are deposits of sodium urate crystals that occur in chronic gout — not osteoarthritis. Swelling, joint pain, and tenderness on palpation occur with a sprain injury.

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

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

Which of the following is a plasma protein associated with the immunologic reaction?

Complement Explanation: Complement is a plasma protein associated with immunologic reactions. Leukotrienes are chemical mediators from constituents of cell membranes. Cytokines are nonantibody proteins that act as intercellular mediators, as in the generation of the immune response. Prostaglandins are lipid-soluble molecules synthesized from constituents of cell membranes.

Which joint is mostly commonly affected in gout?

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

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

Methotrexate (rheumatrex) Explanation: Methotrexate is a DMARD that reduces the amount of joint damage and slows the damage to other tissues as well. Etanercept and Infliximab are TNF-alpha inhibitors that reduce pain and inflammation. Methylprednisolone is a steroid to reduce pain and inflammation and slow joint destruction.

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

Pace yourself and rest frequently, especially after activities Explanation: A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace oneself during daily activities. Telling the client to do chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace oneself and take frequent rests rather than doing all chores at once.

A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse?

The doctor could prescribe anti-inflammatory drugs Explanation: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Antipyretic and antihypertensive drugs are not prescribed for autoimmune diseases. An antineoplastic drug is not ordered for an autoimmune disorder until it is in its late stages and uncontrolled by the first-line drugs.

Which newer pharmacological therapy, used to treat osteoarthritis, is thought to prevent the loss of cartilage and repair chondral defects, as well as have some anti-inflammatory effects?

Viscoupplementation Explanation: Viscosupplementation, the intra-articular injection of hyaluronates, is thought to prevent the loss of cartilage and repair chondral defects. It may also have some anti-inflammatory effects. Glucosamine and chondroitin are thought to improve tissue function and retard breakdown of cartilage. Capsaicin is a topical analgesic.