Chapter 64: Arthritis and Connective Tissue Diseases

A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern should the nurse recommend?

Regular exercise program of walking Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

When reviewing the health record for a new patient with rheumatoid arthritis, the nurse reads that the patient has swan neck deformities. Which deformity should the nurse expect to observe when assessing the patient?

Swan neck deformity involves distal interphalangeal joint hyperflexion and proximal interphalangeal joint hyperextension of the hands. The other deformities are also associated with rheumatoid arthritis: ulnar drift, boutonniere deformity, and hallux vagus.

Which nursing intervention is appropriate for a patient with Sjögren's syndrome?

Use lubricating eyedrops frequently. Rationale: Sjögren's syndrome is an autoimmune disorder in which lymphocytes attack moisture-producing glands. Treatment is symptomatic, including adding moisture to eyes and increasing intake of fluids, especially with meals.

The nurse should determine additional instruction is needed when a patient diagnosed with scleroderma makes which statement?

b. "I should lie down for an hour after each meal." Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate teaching has been effective.

Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient understands the nurse's teaching about the condition?

b. "I will use sunscreen when I am outside." Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

A patient has recently been diagnosed with rheumatoid arthritis (RA) The patient, who has two school-age children, tells the nurse that home life is very stressful. Which initial response should the nurse make?

b. "Tell me more about the situations that are causing you stress." 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.

Which information should the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self-management?

b. A gradual increase in daily exercise may help decrease fatigue. A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with SEID syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. SEID usually does not progress.

How should the nurse suggest that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day?

b. A warm bath followed by a short rest 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.

The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order should the nurse question?

b. Administer varicella vaccine Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Considering this treatment, which information should the nurse report to the health care provider?

b. The patient is trying to get pregnant before her disease becomes more severe. 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.

Which assessment information should indicate to the nurse that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone?

b. The patient's blood glucose is 165 mg/dL. Corticosteroids have the potential to cause diabetes. The finding of elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR with no improvement in symptoms would indicate the prednisone was not effective but would not be side effects of the medication

A 66-yr-old man with type 2 diabetes and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask?

"Have you noticed any bruising or bleeding?" Rationale: Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both may increase the risk of bleeding. Patients with atrial fibrillation routinely take an anticoagulant to reduce the risk of venous thromboembolism and stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose, and hyperglycemia may occur.

The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement?

"I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)." Rationale: Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

he nurse is delivering teaching to a female patient newly diagnosed with systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease?

"I'm hoping surgery will be an option for me in the future." Rationale: Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.

A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate?

"Infertility can result from some medications used to control your disease." Rationale: Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common after pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.

The patient developed acute gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout?

Administration of allopurinol Rationale: To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the patient's aspirin will inactivate its effect, resulting in urate retention. Dietary restrictions that limit alcohol and foods high in purine help minimize uric acid production.

A patient with longstanding Raynaud's phenomenon currently reports red spots on the hands, forearms, palms, face, and lips. Which additional findings would the nurse expect? (Select all that apply.)

Calcinosis Sclerodactyly Difficulty swallowing Skin thickening below the elbow and knee Rationale: This patient is at risk for scleroderma. The acronym CREST represents the manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud's phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.

The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites?

Check for an enlarging reddened area with a clear center. Rationale: After a tick bite, the expanding "bull's eye rash" is the most characteristic symptom that usually occurs in 3 to 30 days. Flu-like symptoms and migrating joint and muscle pain also may be present. Active lesions are treated with oral antibiotics for 2 to 3 weeks; doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. No vaccine is available.

A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan?

Degeneration of articular cartilage in synovial joints Rationale: OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.

The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure should the nurse recommend to slow progression of the disease?

Eat a well-balanced diet to maintain a healthy body weight. Rationale: Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.

The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient's choice of which food item indicates an understanding of the instructions?

Eggs Rationale: Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.

When reinforcing health teaching on managing osteoarthritis, which patient statement indicates additional instruction is needed?

I should try to stay standing all day to keep my joints from becoming stiff." Rationale: Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.

A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments would be included in the plan of care? (Select all that apply.)

Massage therapy Low-impact aerobic exercise Relaxation strategy (biofeedback) Antiseizure drug pregabalin (Lyrica) Serotonin reuptake inhibitor (e.g., sertraline [Zoloft]) Rationale: Massage will improve blood flow and relaxation. Low-impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation using biofeedback may decrease the patient's stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will preferably be prescribed a nonopioid pain medication, an antiseizure medication such as pregabalin to help with widespread pain, and a serotonin reuptake inhibitor for depression. Long-acting opioids such as morphine are avoided unless other medications do not relieve pain.

Which statement suggests a need for the nurse to assess the patient for ankylosing spondylitis?

My lower back pain seems to be getting worse and nothing seems to help." Rationale: AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient's knees?

Pain with joint movement Rationale: Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.

Four patients have been newly diagnosed with connective tissue disorders. The nurse is concerned with safety issues and interstitial lung involvement for the patient with which diagnosis?

Polymyositis Rationale: Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient's risk of falls and injury. Weakened pharyngeal muscles also increase the risk for aspiration, with interstitial lung disease in up to 65% of patients. Safety concerns and interstitial lung involvement are not associated with reactive arthritis (Reiter's syndrome) or Sjögren's syndrome. Safety may be an issue later in disease progression of SLE.

A nurse assesses a patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect? (Select all that apply.)

Presence of nodules Subluxation of joints without fibrous ankyloses Rationale: In stage III severe RA, extraarticular soft tissue lesions or nodules may be present along with subluxation without fibrous or bony ankylosis. Muscle strength is decreased because of extensive muscle atrophy. Manifestations are systemic rather than localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Joint space narrowing with osteophytes is consistent with osteoarthritis.

After teaching a 28-yr-old with fibromyalgia about the disease, which patient statement does the nurse determines indicates a good understanding of effective self-management?

a. "I will need to stop drinking so much coffee and soda." Dietitians often suggest patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management

Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis should the nurse identify as a likely adverse effect of the medication?

a. Blurred vision Plaquenil can cause retinopathy. The medication should be stopped. Other findings are not related to the medication although they will also be reported.

Which action should the nurse include in the plan of care for a patient with newly diagnosed ankylosing spondylitis?

a. Have the patient sleep on their back with a flat pillow Because ankylosing spondylitis results in flexion deformity of the spine, postures that extend the spine (e.g., sleeping on the back and with a flat pillow) are recommended. HLA-B27 antigen is assessed for initial diagnosis but is not needed annually. To counteract the development of flexion deformities, the patient should choose activities that extend the spine, such as swimming. Heat application is used to decrease localized pain.

What finding should indicate to the nurse that colchicine has been effective for a patient with an acute attack of gout?

a. Reduced joint pain Colchicine reduces joint pain in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day during acute gout would increase urine output but would not indicate the effectiveness of colchicine. Elevated serum uric acid would result in increased symptoms. The WBC count might decrease with decreased inflammation but would not increase.

During assessment of the patient with fibromyalgia, the nurse should expect the patient to report which of the following? (Select all that apply.)

a. Sleep disturbances b. Multiple tender points e. Widespread bilateral, burning musculoskeletal pain These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia.

A 25-yr-old female patient with systemic lupus erythematosus (SLE) has a facial rash and alopecia. She tells the nurse, "I never leave my house because I hate the way I look." Which patient problem should the nurse plan to address?

a. Social isolation The patient's statement about not going anywhere because of hating the way he or she looks expresses social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, hot knee. Which assessment finding should the nurse report immediately to the health care provider?

a. The blood pressure is 86/50 mm Hg. The low blood pressure suggests the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding should the nurse report immediately to the health care provider?

a. The patient has painful hematuria. Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

Which information should the nurse include when preparing teaching materials for a patient who has an exacerbation of rheumatoid arthritis?

b. Applying cold packs before exercise may decrease joint pain 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 and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

A patient with gout has a new prescription for losartan (Cozaar). What should the nurse plan to monitor?

b. Blood pressure Losartan may be effective for treating older patients with gout and hypertension. Losartan promotes urate excretion and may normalize serum urate. Losartan, an angiotensin II receptor antagonist, should lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.

Which laboratory result should the nurse monitor to determine if prednisone has been effective for a patient who has an acute exacerbation of rheumatoid arthritis?

b. C-reactive protein C-reactive protein is a serum marker for inflammation, and a decrease would indicate the corticosteroid therapy was effective. Blood glucose and serum electrolytes will also be monitored to assess for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.

A patient with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider?

b. Crackles are auscultated in the lung bases. Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for a change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve symptoms.

Which finding should the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee?

b. Discomfort with joint movement Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests and decreases with joint movement.

Which information should the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about managing the condition?

b. Do daily deep-breathing exercises. Deep-breathing exercises are used to decrease the risk for pulmonary complications that may result from reduced chest expansion that can occur with AS. Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

Which action for the care of a patient who has scleroderma can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

b. Document the patient's oral intake. Monitoring and documenting patient's oral intake is included in UAP education and scope of practice. Assessments for changes in physical status and administration of medications require more education and scope of practice and should be done by RNs.

Which result for a patient with systemic lupus erythematosus (SLE) should the nurse identify as most important to communicate to the health care provider?

b. Elevated blood urea nitrogen (BUN) Elevated BUN and serum creatinine indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows decreased inflammation.

Which action should the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)?

b. Encourage the patient to take a nap in the afternoon. Adequate rest helps decrease the fatigue and pain associated with RA. Patients are taught to avoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When the disease is stabilized, a physical therapist usually develops a therapeutic exercise program that includes exercises that improve flexibility and strength of affected joints, as well as the patient's general endurance.

Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). What information should the nurse include in teaching the patient about this drug?

b. Giving subcutaneous injections. 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 fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued.

A patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action should the nurse include in the plan of care?

b. Keep the environment warm and draft free. Keeping the room warm will decrease the incidence of Raynaud's phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose or to assist the patient to the bathroom every 2 hours.

A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. What safety priority should the nurse identify for this patient?

b. Risk for aspiration The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other concerns are also appropriate but are not as high a priority as the maintenance of the patient's airway.

The nurse is assessing a patient with osteoarthritis who uses naproxen (Naproxyn) for pain management. Which assessment finding should the nurse recognize as likely to require a change in medication?

b. The patient has dark-colored stools Dark-colored stools may indicate the patient is experiencing gastrointestinal bleeding caused by the naproxen. The patient's ongoing pain and weight gain will also be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

The nurse teaches a patient with osteoarthritis (OA) of the hip about how to manage the OA. Which patient statement indicates to the nurse a need for additional teaching?

c. "I will take 1 gram of acetaminophen (Tylenol) every 4 hours." No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease the risk for liver damage. Regular exercise, moist heat, and supportive equipment are recommended for OA management

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." What is the most appropriate response by the nurse?

c. "It is important to start methotrexate early to decrease the extent of joint damage." Disease-modifying antirheumatic 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.

A new clinic patient with joint swelling and pain is having diagnostic tests. Which test should the nurse identify as specific to systemic lupus erythematosus?

c. Anti-Smith antibody (Anti-Sm) The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE

The nurse notices a circular lesion with a red border and clear center on the arm of a patient who is in the clinic reporting chills and muscle aches. Which action should the nurse take to follow up on that finding?

c. Ask the patient about recent outdoor activities. The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest cardiac or abdominal problems or lack of immunization.

A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action should the nurse take?

c. Assess the nodules for skin breakdown or infection. Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

What suggestion should the nurse make to a group of women with rheumatoid arthritis (RA) about managing activities of daily living?

c. Avoid activities requiring repetitive use of the same muscles and joints. 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 joint stress. Patients are encouraged to position joints in the extended (neutral) position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion.

The nurse should anticipate the need to teach a patient who has osteoarthritis (OA) about which medication?

c. Capsaicin cream (Zostrix) Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with rheumatoid arthritis.

Which information from a patient's health history should the nurse identify as a risk factor for septic arthritis?

c. Sexually active with several partners Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.

A patient with rheumatoid arthritis (RA) tells the clinic nurse about having chronically dry eyes. Which action should the nurse take?

c. Suggest the patient use over-the-counter (OTC) artificial tears. The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eyedrops is recommended. Dry eyes are not a side effect of methotrexate. A focus on the prognosis for RA is not helpful. The dry eyes are not caused by RA treatment but by the disease itself.

A patient with an acute attack of gout in the right great toe has a new prescription for probenecid. Which information about the patient's home routine should the nurse understand indicates a need for teaching regarding gout management?

c. The patient takes one aspirin a day to prevent angina. Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

A patient is taking methotrexate to treat rheumatoid arthritis (RA). Which laboratory result is important for the nurse to communicate to the health care provider?

c. The white blood cell count is 1500/µL. 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 elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose is normal.

A patient with hypertension and gout has a red, painful right great toe. Which action should the nurse include in the plan of care for this patient?

c. Use a footboard to hold bedding away from the toe. Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe, and touching the toe should be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain management.

A patient who takes multiple medications develops acute gout arthritis. Which medication should the nurse discuss with the health care provider before administering a prescribed dose?

c. hydrochlorothiazide. Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.

Which patient seen by the nurse in the outpatient clinic is most likely to need teaching about ways to reduce the risk for osteoarthritis (OA)?

d. A 56-yr-old woman who works on an automotive assembly line OA is more likely to occur in women as a result of estrogen reduction at menopause and in persons whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a risk factor for OA. Sedentary work is not a risk factor for OA.

The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information should the nurse discuss with the health care provider for an urgent change in the treatment plan?

d. Laboratory results indicate blood urea nitrogen (BUN) is elevated. Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will be reported to the health care provider but is consistent with the patient's diagnosis of osteoarthritis and will not require an immediate change in the patient's treatment plan.

The home health nurse is making a follow-up visit to a patient recently diagnosed with rheumatoid arthritis (RA). Which finding indicates to the nurse that additional patient teaching is needed?

d. The patient sleeps with two pillows under the head. The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. Rest, aspirin, and energy management are appropriate for a patient with RA and indicate teaching has been effective.

A patient reporting painful urination and knee pain is diagnosed with reactive arthritis. What long-term therapy should the nurse plan to explain to the patient?

d. doxycycline (Vibramycin) Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis.