Prep U Ch. 38 Rheumatoid Arthritis (RA)
The nurse is caring for a client with rheumatoid arthritis who suffers with chronic pain in the hands. When would be the best time for the nurse to perform range-of-motion exercises? a) After the client has had a warm paraffin hand bath b) First thing in the morning when the client wakes c) After the client has a diagnostic test d) After cool compresses have been applied to the hands
a) After the client has had a warm paraffin hand bath Explanation: Whether resting or moving, clients in this stage of the disease have considerable chronic pain, which typically is worse in the morning after a night's rest. Warmth helps decrease the symptoms of pain and will be the best time to perform range of motion exercises. pg.1056
The client with rheumatoid arthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care? a) Reports decreased joint pain b) Reports ability to perform ADLs c) Reports increased fatigue d) Shows a weight gain of 2 pounds
c) Reports increased fatigue Explanation: Fatigue is common with rheumatoid arthritis. Finding a balance between activity and rest is an essential part of the therapeutic regimen. pg.1063
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?
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. pg.1060
Which of the following classifications are considered antiarthritic drugs? Select all that apply. a) Disease-modifying antirheumatics (DMARDs) b) Diuretics c) Anti-inflammatory d) Muscle relaxants e) Glucocorticoids
c) Anti-inflammatory a) Disease-modifying antirheumatics (DMARDs) e) Glucocorticoids Explanation: Antiarthritic drugs fall into three major groups: nonsteroidal anti-inflammatory drugs (NSAIDs), DMARDs, and glucocorticoids. Diuretics and muscle relaxants are not antiarthritic drugs. pg.1056
A patient with an acute exacerbation of arthritis is temporarily confined to bed. What position can the nurse recommend to prevent flexion deformities? a) Supine with pillows under the knees b) Semi-Fowler's c) Side-lying with pillows supporting the shoulders and legs d) Prone
d) Prone Explanation: It is best for the patient with rheumatoid arthritis to lie prone several times daily to prevent hip flexion contracture.
A patient is prescribed a DMARD that is successful in the treatment of RA but has side effects, including retinal eye changes. What medication does the nurse anticipate educating the patient about? a) Azathioprine (Imuran) b) Hydroxychloroquine (Plaquenil) c) Aurothioglucose (Solganal) d) Diclofenac (Voltaren)
b) Hydroxychloroquine (Plaquenil) Explanation: The DMARD hydroxychloroquine (Plaquenil) 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). pg.1060
A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis? a) "My finger joints are oddly shaped." b) "I have pain in my hands." c) "My legs feel weak." d) "I have trouble with my balance."
a) "My finger joints are oddly shaped." Explanation: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities. pg.1066
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? a) Reiter's syndrome b) Ankylosing spondylitis c) Sjögren's syndrome d) Raynaud's phenomenon
d) Raynaud's phenomenon Explanation: Blanching of fingers on exposure to cold is associated with Raynaud's phenomenon. pg.1057
Which of the following would be consistent with the diagnosis of rheumatoid arthritis? a) Increased C4 complement component b) Increased red blood cell count c) Cloudy synovial fluid d) Decreased ESR
c) Cloudy synovial fluid Explanation: In a patient with rheumatoid arthritis, Arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement. pg.1066
A patient has a serum study that is positive for the rheumatoid factor. What does the nurse understand is the significance of this test result? a) Specific for RA b) Diagnostic for Sjögren's syndrome c) Diagnostic for SLE d) Suggestive of RA
d) Suggestive of RA Explanation: Rheumatoid factor is present in about 80% of patients with RA, but its presence alone is not diagnostic of RA, and its absence does not rule out the diagnosis. pg.1066
The nurse is gathering objective data for a client at the clinic complaining of arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. What does the nurse recognize this deformity as? a) Ulnar deviation b) Boutonnière deformity c) Rheumatoid nodules d) Swan neck deformity
d) Swan neck deformity Explanation: A swan neck deformity is a hyperextension of the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. A Boutonnière deformity is a persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint. Ulnar deviation is when the fingers are deviating laterally toward the ulna. A rheumatoid nodule is a subcutaneous nodule. pg.1066
A patient is receiving gold sodium thiomalate (Myochrysine) for the treatment of RA. What does the nurse understand about the action of this compound? a) Inhibits DNA synthesis b) Inhibits lysosomal enzymes c) Inhibits T- and B-cell activity d) Inhibits platelet aggregation
c) Inhibits T- and B-cell activity Explanation: Gold sodium thiolmalate (Myochrysine) inhibits T- and B-cell activity, thereby suppressing synovitis during the active stage of rheumatoid disease. pg.1060
The nurse is performing discharge teaching for a patient with rheumatoid arthritis. What teachings are priorities for the patient? Select all that apply. a) Dressing changes b) Narcotic safety c) Safe exercise d) Medication dosages and side effects e) Assistive devices
c) Safe exercise d) Medication dosages and side effects e) Assistive devices Correct Explanation: The patient who is being discharged to home needs information on how to exercise safely to maintain joint mobility. Medication doses and side effects are always an essential part of discharge teaching. Assistive devices, such as splints or even walkers and canes, may assist the patient to care safely for him- or herself. Narcotics are not commonly used and there would be no reason for dressings. pg.671
A client with rheumatoid arthritis is prescribed a tumor necrosis factor (TNF)-alpha inhibitor. Which of the following might be prescribed? a) Etanercept b) Celecoxib c) Diclofenac d) Indomethacin
a) 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. pg.1061
A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process? a) "It will get better and worse again." b) "It will never get any better than it is right now." c) "When it clears up, it will never come back." d) "I'll definitely need surgery for this."
a) "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. pg.1062
The nurse is teaching a patient about her rheumatic disease. What statement best helps to explain "autoimmunity"? a) "Your symptoms are a result of your body attacking itself." b) "You are not immune to the disease causing the symptoms." c) "You have inherited your parent's immunity to the disease." d) "You have antigens to the disease, but it they do not prevent the disease."
a) "Your symptoms are a result of your body attacking itself." Correct Explanation: In autoimmunity, the body mistakes its own tissue for foreign tissue and begins to attack it. Symptoms develop as the body destroys tissue. The body is in effect "attacking itself." The other statements do not explain autoimmunity. pg.1055
A patient with rheumatoid arthritis is complaining of joint pain. What intervention is a priority to assist the patient? a) Nonsteroidal anti-inflammatory drugs (NSAIDs) b) Opioid therapy c) Surgery d) Ice packs
a) Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment for rheumatoid arthritis pain. They help to decrease inflammation in the joints. Heat is used to relieve pain rather than ice packs. 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. pg.1056
Which of the following clinical manifestations would the nurse expect to find in a client who has had rheumatoid arthritis for several years? a) Small joint involvement b) Asymmetric joint involvement c) Bouchard's nodes d) Obesity
a) Small joint involvement 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. pg.1065
A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? a) Performing meticulous skin care b) Administering ordered analgesics and monitoring their effects c) Providing comprehensive client teaching; including symptoms of the disorder, treatment options, and expected outcomes d) Supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware
b) Administering ordered analgesics and monitoring their effects Explanation: An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management her priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions don't not take priority over pain management. pg.1066
The client with rheumatoid arthritis has a red blood cell count of 3.2 cells/cu mm. Which nursing diagnosis has the highest priority for the client? a) Self-care deficit: Bathing b) Ineffective airway clearance c) Fatigue d) Risk for infection
c) Fatigue Explanation: Low red blood cell count can be related to inadequate nutrition. Insufficient RBC levels compromise the oxygen-carrying capacity of the blood, which can lead to fatigue. pg.1063
Which of the following points should be included in the medication-teaching plan for a patient taking adalimumab (Humira)? a) The medication is administered IM. b) The medication is given at room temperature. c) It is important to monitor for injection site reactions. d) The patient should continue taking the medication if fever occurs.
c) It is important to monitor for injection site reactions. Explanation: It is important to monitor for injection site reactions. The medication is injected subcutaneously and must be refrigerated. The medication should be withheld if fever occurs. pg.1061
Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)? a) Disease-modifying antirheumatic drugs (DMARDS) b) Glucocorticoids c) Nonsteroidal anti-inflammatory drugs (NSAIDs) d) Tumor necrosis factor (TNF) blockers
c) Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: In most patients NSAIDs usually are the first choice in the treatment of RA. The use of traditional NSAIDs and salicylates inhibit the production of prostaglandins and provide anti-inflammatory effects as well as analgesic. In RA, if joint symptoms persist despite use of NSAIDs, the second major drug group known as DMARDs is initiated early in the disease. 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. pg.1056
Which diagnostic study finding is decreased in patients diagnosed with rheumatoid arthritis? a) Uric acid b) Creatinine c) Red blood cell count d) Erythrocyte sedimentation rate (ESR)
c) Red blood cell count Explanation: There is a decreased red blood cell count in patients diagnosed with rheumatic diseases. ESR increases inflammatory connective tissue disease. Uric acid is increased in gout. Increased creatinine may indicate renal damage in SLE, scleroderma, and polyarteritis. pg.1066
A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain? a) Acupuncture b) Cold therapy c) Heat therapy and nonsteroidal anti-inflammatory medications (NSAIDs) d) An exercise routine that includes range-of-motion (ROM) exercises
d) An exercise routine that includes range-of-motion (ROM) exercises Explanation: Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain. pg.1067
The client asks the nurse about types of exercise that do not stress the joints. Which of the following would be an inappropriate type of exercise for the nurse to include in the teaching plan? a) T'ai chi b) Yoga c) Pilates d) Jogging
d) Jogging Explanation: Jogging would be an inappropriate type of exercise, as it is a high impact, jarring type of exercise. pg.1077
The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. Which of the following would the nurse expect to find? a) Elevated erythrocyte sedimentation rate b) Increased albumin levels c) Increased red blood cell count d) Increased C4 complement
a) Elevated erythrocyte sedimentation rate Explanation: The erythrocyte sedimentation rate (ESR) may be elevated, particularly as the disease progresses. ESR shows inflammation associated with RA. Red blood cell count and C4 complement component are decreased. Serum protein electrophoresis may disclose increased levels of gamma and alpha globulin but decreased albumin. pg.1058
A patient is seen in the office for complaints of joint pain, swelling, and a low-grade fever. What blood studies does the nurse know are consistent with a positive diagnosis of RA? (Select all that apply.) a) Positive antinuclear antibody (ANA) b) Positive C-reactive protein (CRP) c) Aspartate aminotransferase (AST) and alanine transaminase (ALT) levels of 7 units/L d) Red blood cell (RBC) count of <4.0 million/mcL e) Red blood cell (RBC) count of >4.0 million/mcL
a) Positive antinuclear antibody (ANA) b) Positive C-reactive protein (CRP) d) Red blood cell (RBC) count of <4.0 million/mcL 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. pg.1066
A client with rheumatoid arthritis has experienced increasing pain and progressing inflammation of the hands and feet. What would be the expected goal of the likely prescribed treatment regimen? a) Eradicating pain b) Promoting sleep c) Eliminating deformities d) Minimizing damage
d) Minimizing damage Explanation: Although RA cannot be cured, much can be done to minimize damage. Treatment goals include decreasing joint inflammation before bony ankylosis occurs, relieving discomfort, preventing or correcting deformities, and maintaining or restoring function of affected structures. Early treatment leads to the best results. pg.1066