med surg chapter 65 arthritis and connective tissue

The nurse is reinforcing general health teaching with a 48-year-old patient with osteoarthritis of the knees. Which statement by the patient demonstrates correct understanding of osteoarthritis?

1 "Joint degeneration with pain and disability occurs in the majority of people by the age of 60." 2 "Osteoarthritis can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication." Correct 3 "Osteoarthritis is more common with aging, but usually it remains confined to a few joints and does not cause crippling." 4 "Osteoarthritis is an inflammatory disease of the joints that may present symptoms at any age." Osteoarthritis occurs with greater frequency with increasing age, but it usually remains confined to a few joints and can be managed with a combination of exercise, diet, and medication. It can be managed, but not prevented, with diet and exercise. Disability at age 60 is not a complication of osteoarthritis and it occurs with advanced age, not at any age.

A patient is suffering from scleroderma. Which symptoms suggest the involvement of an internal organ? Select all that apply.

1 Calcinosis Correct 2 Dysphagia Correct 3 Dental caries 4 Sclerodactyly 5 Telangiectasia Correct 6 Esophageal dysfunction Scleroderma is a disorder of connective tissue and involves inflammatory changes in the skin, blood vessels, skeletal muscles, and internal organs. Symptoms such as dysphagia, dental caries, and esophageal dysfunction are indicative of gastrointestinal involvement. Calcinosis, sclerodactyly, and telangiectasia are external symptoms of scleroderma.

A primary health care provider has prescribed an intraarticular injection of steroids for a patient. Which statement holds true for this type of administration? Select all that apply.

1 It is only used for short-term therapy. Correct 2 The joint should not be overused after injection. 3 It cannot be accompanied with systemic therapy. Correct 4 Sterile technique must be used for steroid injections. Correct 5 A high dose of medication is delivered to the affected joint. The intraarticular injection of steroids is injected directly into the joint space of a painful, inflamed arthritic joint and is often used as an adjunct to systemic therapy. Overuse of the joint is not suggested in the first few hours after an injection, as it can aggravate arthritis. A sterile technique must be used for steroid injections in order to reduce the risk of infection. Generally, a high dose of medication is injected, and the effect lasts a week or month. Intraarticular steroid injections are a part of long-term therapy and are used as an adjunct to systemic therapy.

A patient observes discoloration of urine during the course of the treatment for arthritis. How does the nurse explain this type of observation? Select all that apply.

1 It may be due to an infection. Correct 2 Excess medication is excreted in the urine. 3 This is a side effect of the treatment. Correct 4 This is a result of the interaction between the medications with the urine. Correct 5 It will stop once the therapy is discontinued. Many drugs often cause discoloration of the urine because of the conversion into colored metabolites (metabolism by mostly liver enzymes and not interaction with urine) in the body, which are then excreted in the urine. The discoloration of urine by the drug is due to the excess medicine being excreted in the urine, and the resultant interaction between the drug metabolite and the urine. This side effect vanishes with the discontinuation of the therapy. Infections generally do not cause discoloration. Discoloration of urine is not a side effect of the drug

A nurse is counseling a patient with a history of gout. What are the factors that may precipitate gout? Select all that apply.

1 Peanut butter and nuts 2 Blueberries Correct 3 Starvation Correct 4 Niacin (Niacor) administration Correct 5 Aspirin (Ecotrin) administration Patients having a history of gout should be informed that it may be precipitated by factors like excessive caloric intake or overindulgence in purine-containing foods and alcohol, starvation, and drug use (e.g., niacin, aspirin, and diuretics). Starvation may precipitate a gout attack. The low-fluid intake during starvation can result in low-urine output; the uric acid may not be excreted completely, causing it to crystallize and get despoiled in the joints. Niacin and aspirin decrease the excretion of uric acid through kidneys, causing hyperuricemia. Blueberries, peanut butter, and nuts do not trigger gout attack, as these are low in purine content.

The nurse is reviewing the report of a patient's synovial fluid analysis. Which findings would suggest the presence of rheumatoid arthritis? Select all that apply.

1 Presence of sodium urate crystals 2 Clear yellow in color Correct 3 Presence of fibrin flecks Correct 4 Increased matrix metallopeptidase (MMP) -3 enzyme Correct 5 Elevated white blood cell (WBC) count The presence of fibrin flecks in the synovial fluid indicates rheumatoid arthritis. There is also an increase in MMP-3 enzyme, which indicates progressive joint damage. The WBC count is usually elevated up to 25,000 cells per microliters. Presence of sodium urate crystals in synovial fluid is indicative of gout. A clear yellow synovial fluid is found in osteoarthritis.

The nurse is caring for a patient with mucocutaneous lesions, urethritis, and conjunctivitis. Which drug therapy does the nurse expect the primary health care provider to prescribe for the patient? Select all that apply.

A Pregabalin (Lyrica) B Infliximab (Remicade) Correct C Nifedipine (Afeditab CR) Correct D Methotrexate (Otrexup) Correct E Sulfasalazine (Azulfidine) F Ibuprofen (Advil) Mucocutaneous lesions, urethritis, and conjunctivitis are the clinical signs of reactive arthritis. Methotrexate is used in the treatment of mucocutaneous lesions. Sulfasalazine is used to treat chronic inflammation. Nonsteroidal antiinflammatory drugs such as ibuprofen (Advil) are given in the initial stages of reactive arthritis. Pregabalin (Lyrica) is used to treat anxiety or peripheral neuropathic pain. This medication is not indicated for a patient with mucocutaneous lesions, urethritis, and conjunctivitis. Nifedipine (Afeditab CR) is a vasodilator that helps decrease arterial blood pressure. Infliximab (Remicade) is a tissue necrotic factor (TNF) inhibitor used in the treatment of patients with ankylosing spondylitis (AS)

A patient has been prescribed diclofenac sodium (Voltaren Gel). What precautions should be taken with its use? Select all that apply.

Correct 1 Avoid exposure to sunlight. 2 Antacids should be used concomitantly. 3 Sunscreen should be used concomitantly. Correct 4 Avoid external heat or occlusive dressings. Correct 5 Do not coadminister with oral aspirin (Ecotrin). Diclofenac sodium is a nonsteroidal antiinflammatory drug. Its gel form is used topically to the affected joints. When using the drug, exposure to sunlight should be avoided to prevent ultraviolet ray-induced skin tumors (reported in animals). Also the use of external heat or occlusive dressing can lead to burns. Coadministration of oral aspirin should not be done due to the potential for increased side effects. Concomitant use of sunscreen lotion should be avoided, as it may result in skin reactions or change the absorption of the drug. Antacids are generally used for oral NSAIDs and not as topical formulations.

A 40-year-old African-American woman has had Raynaud's phenomenon for some time. She is now reporting red spots on the hands, forearms, palms, face, and lips. What other manifestations should the nurse assess for when assessing for scleroderma? Select all that apply. .

Correct 1 Calcinosis 2 Weight loss Correct 3 Sclerodactyly Correct 4 Difficulty swallowing 5 Weakened leg muscles This 40-year-old African-American woman is at risk for scleroderma. The acronym CREST represents the clinical 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; T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.

Septic arthritis requires prompt treatment to prevent joint destruction and bone loss. Which nursing interventions would help achieve this goal? Select all that apply. .

Correct 1 Explain need of antibiotics to patient. 2 Ensure adherence to corticosteroid therapy. Correct 3 Support the patient who requires operative drainage. Correct 4 Assist in early identification of the causative organism. Correct 5 Assess and monitor joint inflammation, pain, and fever. Correct 6 Suggest use of resting splints to immobilize affected joints. Septic arthritis is caused by microorganisms invading the joint cavity. The early identification of the microorganism is achieved by blood cultures. In order to meet the goal of the therapy, the patient adherence to antibiotic therapy is vital. During the course of therapy, joint inflammation, pain, and fever should be monitored. The use of resting splints to immobilize affected joints during disease flare-ups protects the joint. In case of sepsis, the patient should be supported in operative drainage. Corticosteroids are not used in the management of septic arthritis.

The nurse is planning the discharge teaching for a patient with rheumatoid arthritis. Which alternative therapies should the nurse suggest? Select all that apply.

Correct 1 Hypnosis Correct 2 Use of a firm mattress 3 Aerobic exercises Correct 4 Transcutaneous electrical nerve stimulation 5 Vigorous range-of-motion exercises The pain involved in rheumatoid arthritis poses a lot of distress in the patient. Hypnosis helps in reducing the psychological stress along with relaxing the mind and body. Using a firm mattress helps in maintaining the proper body alignment and reduces the risk of stiffness. Transcutaneous electrical nerve stimulation helps in maintaining the functionality of the nerves. Aerobic and vigorous range-of-motion exercises should not be done because of the increased risk of joint injury, pain, and inflammation. A rheumatic collaborative care plan should be a mixed program of joint movements, rest, and mind and body relaxation.

The patient with fibromyalgia is suffering with pain at 12 of the 18 identification sites, including the neck and upper back and the knees. The patient also reports nonrefreshing sleep, depression, and being anxious when dealing with multiple tasks. About what treatments should the nurse teach this patient? Select all that apply.

Correct 1 Low-impact aerobic exercise Correct 2 Relaxation strategy (biofeedback) Correct 3 Antiseizure drug pregabalin (Lyrica) 4 Morphine sulfate extended release tablets Correct 5 Serotonin reuptake inhibitor (e.g. sertraline [Zoloft]) Low impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation can help decrease the patient's stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will be prescribed something for pain, such as pregabalin, and a serotonin reuptake inhibitor for depression. Long-acting opioids generally are avoided unless pain cannot be relieved by other medications.

A nurse is instructing a group of caregivers about the home care of a patient with rheumatoid arthritis. What are the instructions that the nurse should include in the teaching? Select all that apply.

Correct 1 Perform aquatic exercise in warm water. Correct 2 Never place pillows below the knees. 3 Ensure complete bed rest for patients. 4 Apply heat for at least 30-60 minutes. Correct 5 Use lifts and elevators instead of the stairs. The goals of rheumatoid arthritis therapy include satisfactory pain management and minimal loss of functional ability of the affected joints. Aquatic exercise in warm water helps in pain management. It helps relieve joint stiffness and allows the patient to perform daily activities more comfortably. Good body alignment while resting can be maintained, and to decrease the risk of joint contracture, pillows should never be placed under the knees. A small, flat pillow may be used under the head and shoulders. Lifts and elevators should be used rather than stairs to help protect the affected joint. Patients with RA should alternate between rest and activity regimens. Heat application should not exceed 20 minutes at a time, as it may aggravate the condition.

The nurse is caring for four newly diagnosed patients with various connective tissue disorders. The nurse should be most aware of safety issues and interstitial lung involvement in the patient with which diagnosis?

Correct 1 Polymyositis 2 Reactive arthritis 3 Sjögren's syndrome 4 Systemic lupus erythematosus (SLE) 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 increase the risk for aspiration with interstitial lung disease in up to 65% of patients. The treatment of polymyositis starts with high-dose corticosteroids that cause immunosuppression. If this does not work, other immunosuppressive drugs may be used. Reactive arthritis (Reiter's syndrome) occurs with urethritis, conjunctivitis, and mucocutaneous lesions, with the asymmetric arthritis involving large joints of the lower extremities and toes. This patient is not at increased risk for safety problems. Sjögren's syndrome decreases moisture produced by exocrine glands, especially in the mouth and eyes, and is without increased risk of injury or interstitial lung involvement. SLE is a multisystem inflammatory autoimmune disorder treated with NSAIDs and antimalarial agents. Safety would not be an important issue early in the disease

A nurse is reviewing the case of a patient suspected of having arthritis. Which differentiating factors should be considered when analyzing the type as rheumatoid arthritis or osteoarthritis? Select all that apply.

Correct 1 Presence of nodules Correct 2 The type of joints affected 3 Presence of rheumatoid factor Correct 4 The characteristics of pain Osteoarthritis generally affects weight-bearing joints such as the knees and hips and the cervical and lumbar spine, whereas rheumatoid arthritis first occurs in the smaller joints like wrists, elbows, and shoulders. For rheumatoid arthritis, the nodules are present especially on extensor surfaces, and stiffness lasts for 1 hour to all day and may decrease with use. For rheumatoid arthritis, stiffness occurs on arising but usually subsides after 30 minutes with use of the joint. In osteoarthritis, the joint pain gradually worsens with joint use and disease progression and gets relieved with rest. Rheumatoid factor is not found to be positive in all patients with rheumatoid arthritis, and it is not an appropriate diagnostic tool.

A pregnant patient is diagnosed with systemic lupus erythematosus (SLE). Which information about associated complications should be given to the patient? Select all that apply.

Correct 1 Stillbirth and spontaneous abortion Correct 2 Intrauterine growth retardation 3 Aggravation of disease due to pregnancy Correct 4 High maternal and fetal risk due to organ involvement 5 Therapeutic termination recommended in majority of cases SLE is characterized by the production of a large variety of autoantibodies against nucleic acids and various self-proteins and internal organ involvement posing a threat to the fetus and the mother. The SLE patient should understand that spontaneous abortion, stillbirth, and intrauterine growth retardation may occur because of deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is a high maternal and fetal risk due to organ involvement of renal, cardiovascular, pulmonary, and central nervous systems. Exacerbation of the disease is common during postpartum period. If proper therapeutic management and monitoring is done, therapeutic termination may not be required, and the patient can give birth to a healthy baby.

What are the clinical manifestations of scleroderma? Select all that apply.

A Uveitis B Cervicitis Correct C Calcinosis D Dysphonia E Bull's eye rash Correct F Raynaud's phenomenon Scleroderma is a connective tissue disorder characterized by painful deposits of calcium in the skin or calcinosis and abnormal blood flow in response to stress identified as Raynaud's phenomenon. Ankylosing spondylitis is associated with uveitis or intraocular inflammation. Reactive arthritis is characterized by cervicitis or inflammation of the cervix. Dysphonia is a symptom of polymyositis and dermatomyositis. Bull's eye rash is a skin lesion caused by tick bite and associated with Lyme disease.

A nurse is teaching a group of caregivers how to remove ticks from the body. What should be the sequence of events in the teaching?

correct 1. Remove attached ticks with tweezers. Correct 2. Wash bitten area with soap and water. Correct 3. Apply antiseptic to the skin. Correct 4. Wash the hands with soap and water. The first thing to be done when the tick bites is to remove the tick. The attached tick should be removed with tweezers and not fingers. The tick's mouth parts should be grasped as close to skin as possible and gently pulled straight out without twisting or jerking. The bitten area should be washed with soap and water, and antiseptic should be applied followed by washing hands. The health care provider should be contacted immediately if flu-like symptoms or a bull's eye rash appears within 2-30 days after removal of tick.

The nurse is caring for a patient on systemic hydrocortisone (Solu-Cortef) for the treatment of arthritis. Which parameters should the nurse monitor in the patient? Select all that apply.

Correct 1 Body weight 2 Renal function Correct 3 Blood pressure Correct 4 Potassium level 5 Hepatic function Corticosteroids like hydrocortisone cause various fluid electrolyte imbalances like sodium retention, fluid retention, congestive heart failure in susceptible patients, potassium loss, calcium loss, and hypertension and should be monitored. Furthermore, corticosteroids cause weight gain, which may worsen the joint condition. Monitoring hepatic function and renal function is not required.