Musculoskeletal problems
A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor a. blood glucose. c. erythrocyte count. b. blood pressure. d. lymphocyte count.
ANS: B Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.
A patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of a. sertraline (Zoloft). b. famotidine (Pepcid). c. hydrochlorothiazide. d. oxycodone (Roxicodone).
ANS: A Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.
In which order will the nurse implement these interprofessional interventions prescribed for a patient admitted with acute osteomyelitis with a temperature of 101.2° F? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain blood cultures from two sites. b. Administer dose of gentamicin 60 mg IV. c. Send to radiology for computed tomography (CT) scan of right leg. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever.
ANS: A, B, D, C The highest treatment priority for possible osteomyelitis is initiation of antibiotic therapy, but cultures should be obtained before administration of antibiotics. Addressing the discomfort of the fever is the next highest priority. Because the purpose of the CT scan is to determine the extent of the infection, it can be done last
The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding a. reduced joint pain. c. elevated serum uric acid. b. increased urine output. d. increased white blood cells (WBC).
ANS: A 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.
The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should a. avoid activities requiring repetitive use of the same muscles and joints. b. protect the knee joints by sleeping with a small pillow under the knees. c. stand rather than sit when performing daily household and yard chores. d. strengthen small hand muscles by wringing out sponges or washcloths.
ANS: A 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.
Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? a. Blurred vision c. Abdominal cramping b. Joint tenderness d. Elevated blood pressure
ANS: A Plaquenil can cause retinopathy. The medication should be stopped. Other findings are not related to the medication although they will also be reported.
A 25-yr-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." The nurse will plan interventions with the patient to address the nursing diagnosis of a. social isolation. c. impaired skin integrity. b. activity intolerance. d. impaired social interaction.
ANS: A 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.
Which action will the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? a. Instruct the patient to purchase a soft mattress. b. Encourage the patient to take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.
ANS: B 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 therapeutic exercise program is usually developed by a physical therapist to include exercises that improve flexibility and strength of affected joints, as well as the patient's general endurance
Which laboratory result will the nurse monitor to determine if prednisone has been effective for a patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose c. Serum electrolytes b. C-reactive protein d. Liver function tests
ANS: B 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.
Which information will the nurse include when preparing teaching materials for a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Applying cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.
ANS: B 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
Which assessment information obtained by the nurse indicates a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? a. The patient has joint pain and stiffness. b. The patient's blood glucose is 165 mg/dL. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.
ANS: B Corticosteroids have the potential to cause diabetes mellitus. 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.
Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is likely to require a change in medication? a. The patient has gained 3 lb. b. The patient has dark-colored stools. c. The patient's pain affects multiple joints. d. The patient uses capsaicin cream (Zostrix).
ANS: B 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.
Which result for a patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep
ANS: B 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.
A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care? a. Quadriceps-setting exercises b. Immobilization of the left leg c. Positioning the left leg in flexion d. Assisted weight-bearing ambulation
ANS: B Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fracture. Weight-bearing exercise increases the risk for pathologic fractures. Flexion of the affected limb is avoided to prevent contractures.
Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? a. Presence of Heberden's nodules b. Discomfort with joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement
ANS: B 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.
The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. c. Naproxen (Aleve) 200 mg BID. b. Administer varicella vaccine. d. Famotidine (Pepcid) 20 mg daily.
ANS: B 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. Which information from the patient's health history is important for the nurse to report to the health care provider related to the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age related macular degeneration of the retina d. he patient has been using large doses of vitamins and health foods to treat the RA.
ANS: B 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 nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma? a. Monitor for difficulty in breathing. b. Document the patient's oral intake. c. Check finger strength and movement. d. Apply capsaicin (Zostrix) cream to hands.
ANS: B 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
After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. "I can exercise every day to help maintain joint motion." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."
ANS: B 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.
Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient has understood the nurse's teaching about the condition? a. "I will exercise even if I am tired." b. "I will use sunscreen when I am outside." c. "I should avoid nonsteroidal antiinflammatory drugs." d. "I should take birth control pills to avoid getting pregnant."
ANS: B 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.
The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a. a brief routine of isometric exercises. b. a warm bath followed by a short rest. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.
ANS: B 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.
A patient with two school-age children has recently been diagnosed with rheumatoid arthritis (RA) and tells the nurse that home life is very stressful. Which initial response by the nurse is most appropriate? a. "You need to see a family therapist for some help with stress." b. "Tell me more about the situations that are causing you stress." c. "Your family should understand the impact of your rheumatoid arthritis." d. "Perhaps it would be helpful for your family to be involved in a support group.
ANS: B 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.
A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching? a. How to apply warm packs to the leg to reduce pain b. How to monitor and care for a long-term IV catheter c. The need for daily aerobic exercise to help maintain muscle strength d. The reason for taking oral antibiotics for 7 to 10 days after discharge
ANS: B The patient will be taking IV antibiotics for several months. The patient will need to recognize signs of infection at the IV site and know how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.
Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. avoiding concurrent aspirin use. b. symptoms of gastrointestinal (GI) bleeding. c. self-administration of subcutaneous injections. d. taking the medication with at least 8 oz of fluid.
ANS: C 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 nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued
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 indicates a need for teaching regarding gout management? a. The patient sleeps 8-10 hours each night. b. The patient usually eats beef once a week. c. The patient takes one aspirin a day to prevent angina. d. The patient usually drinks about 3 quarts water each day.
ANS: C 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.
The nurse is planning care for a patient with hypertension and gout who has a red, painful right great toe. Which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the right foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach the patient to avoid use of acetaminophen (Tylenol).
ANS: C 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.
Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)? a. Rheumatoid factor is positive. b. Fasting blood glucose is 90 mg/dL. c. The white blood cell (WBC) count is 1500/µL. d. The erythrocyte sedimentation rate is elevated
ANS: C 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.
.The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which medication? a. Prednisone c. Capsaicin cream (Zostrix) b. Adalimumab (Humira) d. Sulfasalazine (Azulfidine)
ANS: C 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.
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." The most appropriate response by the nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."
ANS: C 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 patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse identifies a need for additional teaching related to health maintenance when the nurse finds that the patient a. is frustrated with the length of treatment required. b. takes and records the oral temperature twice a day. c. is unable to plantar flex the foot on the affected side. d. uses crutches to avoid weight bearing on the affected leg.
ANS: C Foot drop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis
Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis? a. Ask the patient about any nausea. b. Obtain the patient's oral temperature. c. Review the patient's serum creatinine. d. Change the prescribed wet-to-dry dressing.
ANS: C Gentamicin is nephrotoxic and can cause renal failure as reflected in the patient's serum creatinine. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.
Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)? a. A 56-yr-old man who has a sedentary office job b. A 38-yr-old man who plays on a summer softball team c. A 56-yr-old woman who works on an automotive assembly line d. A 38-yr-old woman who is newly diagnosed with diabetes mellitus
ANS: C OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals 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.
Which nursing action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Check ability to plantar and dorsiflex the foot. b. Determine the patient's readiness to ambulate. c. Log roll the patient from side to side every 2 hours. d. Ask about pain management with the patient-controlled analgesia (PCA).
ANS: C Repositioning a patient is included in the education and scope of practice of UAP, and experienced UAP will be familiar with how to maintain alignment in the postoperative patient. Evaluation of the effectiveness of pain medications, assessment of neurologic function, and evaluation of a patient's readiness to ambulate after surgery require higher level nursing education and scope of practice.
A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules
ANS: C 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.
A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep
ANS: C 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 summer camp counselor who is in the clinic complaining of chills and muscle aches. Which action should the nurse take to follow up on that finding? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.
ANS: C 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.
Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider? a. Serous wound drainage c. Right arm pain with movement b. Right arm muscle spasms d. Temperature 101.4° F (38.6° C)
ANS: D An elevated temperature suggests possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.
The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information requires a discussion with the health care provider about an urgent change in the treatment plan? a. Knee crepitation is noted with normal knee range of motion. b. Patient reports embarrassment about having Heberden's nodes. c. Patient's knee pain while golfing has increased over the last year. d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.
ANS: D Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will also 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.
A patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with a. methotrexate c. etanercept (Enbrel). b. anakinra (Kineret). d. doxycycline (Vibramycin)
ANS: D 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.
The home health nurse is making a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates more patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins each day. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head
ANS: D 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.
