Management of Osteoarthritis and Rheumatoid Arthritis in Older Adults, Exams of Nursing

Download Management of Osteoarthritis and Rheumatoid Arthritis in Older Adults and more Exams Nursing in PDF only on Docsity!

Chapter 18: Care of Patients with Arthritis and Other

Connective Tissue Diseases MULTIPLE CHOICE

1. A nurse is working with a community group promoting healthy aging. What recommendation is best to helpprevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. - Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs d. Engage in weight-bearing exercise.
2. A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) -. However, the first-line drug is acetaminophen b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)
3. The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most appropriate? a. Are you compliant with following the diabetic diet? b. Have you been taking glucosamine supplements? - OA, and glucosamine can increase blood glucose levels c. How much exercise do you really get each week? d. You’re still taking your diabetic medication, right?
4. The nurse working in the orthopedic clinic knows that a client with which factor has an absolutecontraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis - Osteoporosis is a contraindication to joint replacement because the bones have a highrisk of shattering as the new prosthesis is implanted d. Urinary tract infection
5. An older client has returned to the surgical unit after a total hip replacement. The client is confused andrestless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four siderails up. c. Restrain the clients hands.

d. Use an abduction pillow. - To prevent the hip from dislocating, the nurse should use an abduction pillowsince the client cannot follow directions at this time.

6. What action by the perioperative nursing staff is most important to prevent surgical wound infection in aclient having a total joint replacement? a. Administer preoperative antibiotic as ordered. - To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery b. Assess the clients white blood cell count. c. Instruct the client to shower the night before. d. Monitor the clients temperature postoperatively.

7. The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls thesurgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. - Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.
8. A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine whilethe client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower siderail on the affected side. - Because the clients leg is strapped into the CPM, if it falls off the bed due to movement, the clients leg (and new joint) can be injured. The nurse should instruct the UAPto raise the siderail to prevent this from occurring d. Remind the client to do quad-setting exercises.
9. After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse performnext? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. - With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. d. Palpate the clients bladder or perform a bladder scan.
10. A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which actionby the nurse is most important? a. Administering pain medication before transport b. Answering any last-minute questions by the client c. Ensuring the family has directions to the facility d. Providing a verbal hand-off report to the facility - As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error
11. A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating

b. Client with a red, hot, swollen right wrist - the presence of one joint that is much redder, hotter, or moreswollen that the other joints may indicate infection c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

12. A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning fromsurgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the clients chart. c. Encourage range of motion of the neck. d. Notify the provider immediately. - Clients with RA can have cervical joint involvement. This can lead to an

emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after

13. The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjgrens syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity - Sjgrens syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur
14. The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem arebeing met? a. Attends meetings of a book club - Clients who have a poor body image are often reluctant to appear inpublic, so attending public book club meetings indicates that goals for this client problem are being met b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints
15. A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? a. Giving subcutaneous injections - Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self- administer the medication. b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site
16. The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz ) - Tofacitinib carries a FDA black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis.

17. A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs - Ice is best for acute inflammation c. Splints d. Wax dip
18. The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse toassess the client further? a. Creatinine: 3.9 mg/dL - Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. b. Platelet count: 210,000/mm c. Red blood cell count: 5.2/mm d. White blood cell count: 4400/mm

19. A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. - Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.
20. A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acuteexacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. - SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans forthis event not only will decrease the disruption but will give the client a sense of having more control. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.
21. A nurse is caring for a client with systemic sclerosis (SSC). The clients facial skin is very taut, limiting the clients ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what otherconsultation should the nurse facilitate? a. Dentist - With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encouragethe client to see a dentist. b. Massage therapist c. Occupational therapy d. Physical therapy
22. The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Whichstatement by the nurse is most appropriate? a. Drink 1 to 2 liters of water each day. - Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from occurring b. Have 10 to 12 ounces of juice a day. c. Liver is a good source of iron. d. Never eat hard cheeses or sardines.
23. A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi ). What information is most important to include? a. Avoid large crowds or people who are ill. - This drug has a FDA black box warning about opportunistic or other serious infections. Teach the client to avoid large crowds and people who are ill. b. Stay upright for 1 hour after taking this drug. c. This drug may cause your hair to fall out. d. You may double the dose if pain is severe.

24. A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started acting up, especially both hips and knees.What action by the nurse is best? a. Assess the client for the presence of subcutaneous nodules or Bakers cysts. - Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurseshould assess for other manifestations of this disorder, including subcutaneous nodules and Bakers cysts. b. Inspect the clients feet and hands for podagra and tophi on fingers and toes. c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again.

25. A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the clients white blood cell count. b. Culture any drainage from the wound. c. Monitor the clients temperature every 4 hours. d. Use aseptic technique for dressing changes. - Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains.
26. A nurse is discharging a client after a total hip replacement. What statement by the client indicates goodpotential for self-management? a. I can bend down to pick something up. b. I no longer need to do my exercises. c. I will not sit with my legs crossed. - There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hip d. I wont wash my incision to keep it dry.
27. The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated sometasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse? a. Checking to see if the machine is working b. Keeping controls in a secure place on the bed c. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal - For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor
28. A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. I always wear long sleeves, pants, and a hat when outdoors. - Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds. b. I try not to use cosmetics that contain any type of sunblock. c. Since I tend to sweat a lot, I use a lot of baby powder. d. Since I can’t be exposed to the sun, I have been using a tanning bed.
29. A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic andthe surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. - The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed

c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.

30. An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. Whatintervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). - This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the clients red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

31. A client is getting out of bed into the chair for the first time after an uncemented hip replacement. Whataction by the nurse is most important? a. Have adequate help to transfer the client. - The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the clients leg.
32. A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best? a. A little sedation will help you get some rest. b. Depression often accompanies fibromyalgia. c. This drug works in the brain to decrease pain. - Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia d. You will have more energy after taking this drug.
33. A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the clients culture more thoroughly. - The nurse needs a more thorough understanding of the clientsculture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.
34. A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a babyblanket before the birth of her grandchild. What response by the nurse is best? a. Lets ask the provider about increasing your pain pills. b. Hold ice bags against your hands before quilting. c. Try a paraffin wax dip 20 minutes before you quilt. - Paraffin wax dips are beneficial for decreasing painin arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. d. You need to stop quilting before it destroys your fingers.
35. A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important?

a. Be sure you get enough sleep at night. b. Eat plenty of high-protein, high-iron foods. c. Notify your provider at once if you get a fever. - Fever is the classic sign of a lupus flare and should be reported immediately d. Weigh yourself every day on the same scale.

36. A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assessthe client for Heberdens nodules. What assessment technique is correct? a. Inspect the clients distal finger joints. - Herberdens nodules are seen in osteoarthritis and are bony nodulesat the distal interphalangeal joints. To assess for this finding, the nurse inspects the clients distal fingertips b. Palpate the clients abdomen for tenderness. c. Palpate the clients upper body lymph nodes.

d. Perform range of motion on the clients wrists.

37. A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, thehealth care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with the health care provider about administering both drugs to the client. - Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

MULTIPLE RESPONSE

1. The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all thatapply.) a. It affects single joints only.

b. Antibodies lead to inflammation.

c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.

2. A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.)

a. Avoid acetaminophen in over-the-counter medications.

b. It may take several weeks to become effective on pain. c. Pregnancy and breast-feeding are not affected by MTX.

d. Stay away from large crowds and people who are ill.

e. You may find that folic acid, a B vitamin, reduces side effects.

MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.

3. A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select allthat apply.) a. Acupuncture b. Stretching c. Supplements d. Tai chi e. Vigorous aerobics ANS: A, B, D

There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture,

stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.

4. The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia

b. Feltys syndrome

c. Joint deformity d. Low-grade fever

e. Weight loss

Late manifestations of RA include Feltys syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

5. An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless.What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Apply an abduction pillow to the clients legs.

b. Assess the skin under the abduction pillow straps.

c. Place pillows under the heels to keep them off the bed.

d. Monitor cognition to determine when the client can get up.

e. Take and record vital signs per unit/facility policy.

The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurses responsibility, although if the UAP notices abnormalities, he or she should report them.

Determining when the client is able to get out of bed is also a nursing responsibility.

6. The nurse is working with clients who have connective tissue diseases. Which disorders are correctly pairedwith their manifestations? (Select all that apply.)

a. Dry, scaly skin rash Systemic lupus erythematosus (SLE)

b. Esophageal dysmotility Systemic sclerosis c. Excess uric acid excretion Gout d. Footdrop and paresthesias Osteoarthritis

e. Vasculitis causing organ damage Rheumatoid arthritis

A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and paresthesias occur in rheumatoid arthritis.

7. A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctlymatched? (Select all that apply.) a. Allopurinol (Zyloprim) Acute gout

b. Colchicine (Colcrys) Acute gout

c. Febuxostat (Uloric) Chronic gout

d. Indomethacin (Indocin) Acute gout

e. Probenecid (Benemid) Chronic gout

Acute gout can be treated with colchicine and indomethacin. Chronic gout can be treated with febuxostat and probenecid. Allopurinol is used for chronic gout.

8. The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegateto the unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Collaborate with a registered dietitian for appropriate foods. b. Inspect the skin and note any areas of ulceration.

c. Keep the room at a comfortably warm temperature.

d. Place a foot cradle at the end of the bed to lift sheets.

e. Remind the client to elevate the head of the bed after eating.

The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynauds phenomenon. The UAP can adjust the room temperature for the clients comfort. Keeping the sheets off the feet will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can remind the client of this once he or she has been taught. The other actions are performed by the registered nurse.

9. A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What optionscan the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.)

a. Grab bars to reach high items

b. Long-handled bath scrub brush c. Soft rocker-recliner chair

d. Toothbrush with built-up handle

e. Wheelchair cushion for comfort

Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.

10. A home health care nurse is visiting a client discharged home after a hip replacement. The client is still onpartial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.)

a. Buy and install an elevated toilet seat.

b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first.

d. Remove all throw rugs throughout the house.

e. Use a shower chair while taking a shower.

Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

11. A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which isalways difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.)

a. Allow the client uninterrupted rest time.

b. Assess the clients usual bedtime routine.

c. Limit environmental noise as much as possible.

d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping pill.

Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the clients usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.

12. A client has a possible connective tissue disease and the nurse is reviewing the clients laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select allthat apply.) a. Elevated antinuclear antibody (ANA) Normal value; no connective tissue disease b. Elevated sedimentation rate Rheumatoid arthritis c. Lowered albumin Indicative only of nutritional deficit

d. Positive human leukocyte antigen B27 (HLA-B27) Reiters

syndrome or ankylosing spondylitis

e. Positive rheumatoid factor Possible kidney disease

The HLA-B27 is diagnostic for Reiters syndrome or ankylosing spondylitis. A positive rheumatoid factor can be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation.

321

1. In assessing the joints of a patient with rheumatoid arthritis, the nurse understands that the joints aredamaged by (select all that apply)

a.bony ankylosis following inflammation of the joints

b. the deterioration of cartilage by proteolytic enzymes c. the development of Heberden's nodes in the joint capsuled.. increased cartilage and bony growth at the joint margins

e. invasion of pannus into the joint causing a loss of cartilage

Rationale: Bony ankylosis is the union of the bones of a joint by proliferation of bone cells, resulting in complete immobility. Bony ankylosis occurs with advanced rheumatoid arthritis. Joint changes from chronic inflammation begin when the hypertrophied synovial membrane invades the surrounding cartilage, ligaments, tendons, and joint capsule. Pannus (i.e., highly vascular granulation tissue) forms within the joint. It eventually covers and erodes the entire surface of the articular cartilage. The production of inflammatory cytokines at the pannus-cartilage junction further contributes to cartilage destruction. The pannus scars and shortens supporting structures such as tendons and ligaments, ultimately causing joint laxity, subluxation, and contracture.

2. Assessment data in the patient with osteoarthritis commonly include a. gradual weight loss b. elevated WBC count

c. joint pain that worsens with use

d. straw-colored synovial fluid Correct answer: c

Rationale: Osteoarthritis pain ranges from mild discomfort to significant disability. Joint pain is the predominant symptom, and the pain generally worsens with joint use.

3. When administering medications to the patient with gout, the nurse would recognize which of the followingas a treatment for chronic disease? a. Colchicine

b. Febuxostat

c. Sulfasalazine d. Cyclosporine

Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for long-term management of

hyperuricemia in persons with chronic gout. Acute gouty arthritis is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs).

In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes

a. circulating immune complexes formed from IgG autoantibodies reacting with IgG b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles

d. the production of a variety of autoantibodies directed against

components of the cell nucleus

Rationale: Systemic lupus erythematosus (SLE) is characterized by the production of many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins. Autoimmune reactions characteristically are directed against constituents of the cell nucleus (e.g., antinuclear antibodies [ANAs]), particularly DNA. Circulating immune complexes containing antibody against DNA are deposited in the basement membranes of capillaries in the kidneys, heart, skin, brain, and joints. Complement is activated, and inflammation occurs. The overaggressive antibody response is also related to activation of B and T cells. The specific manifestations of SLE depend on which cell types or organs are involved. SLE is a type III hypersensitivity response.

When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to (select all that apply)

a. avoiding the consumption of high-purine foods

b. strategies for good dental hygiene and mouth care

c. protecting the extremities from hot and cold temperatures

d. maintaining joint function and preserving muscle strength

e. performing mouth excursion (yawning) exercises on a daily basis

Rationale: Systemic sclerosis (SS), or scleroderma, is a disorder of connective tissue characterized by fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs. The nurse should include the following in the teaching plan for a patient with SS: daily oral hygiene (neglect may increase tooth and gingival problems); protection of hands and feet from cold exposure and possible burns or cuts (wounds heal slowly); avoidance of emotional stress and cold ambient temperatures (they aggravate Raynaud's phenomenon); isometric exercises for arthropathy (no joint movement occurs); use of assistive devices as appropriate and organization of activities to preserve strength and reduce disability; and mouth excursion (i.e., yawning with an open mouth) (helps maintain temporomandibular joint function).

4. The nurse is working with a 73-year-old patient with osteoarthritis (OA). In assessing the patient's understanding of this disorder, the nurse concludes teaching has been effective when the patient describesthe condition as which of the following?

A. Joint destruction caused by an autoimmune process

B. Degeneration of articular cartilage in synovial joints

C. Overproduction of synovial fluid resulting in joint destruction D. Breakdown of tissue in non-weight-bearing joints by enzymes

Rationale: OA is a degeneration or breakdown of the articular cartilage in synovial joints. The condition has also been referred to as degenerative joint disease.

5. The nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes whichof the following activity patterns?

A. Bed rest with bathroom privileges B. Daily high-impact aerobic exercise

C.A regular exercise program of walking

D. Frequent rest periods with minimal exercise Correct answer: C. A regular exercise program of walking

Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in the patient with osteoarthritis.

6. The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Whichof the following findings would the nurse expect to be present on examination of the patient's knees?

A. Ulnar drift

B. Pain with joint movement

C. Reddened, swollen affected joints D. Stiffness that increases with movementCorrect answer: B. Pain with joint movement

Rationale: OA is characterized predominantly by joint pain upon movement and is a classic feature of the disease.

7. The nurse is caring for a patient who has osteoarthritis (OA) of the knees. The nurse teaches the patient thatthe most beneficial measure to protect the joints is to do which of the following?

A. Use a wheelchair to avoid walking as much as possible.

B. Eat a well-balanced diet to maintain a healthy body weight.

C. Incorrect Use a walker for ambulation to relieve the pressure on her hips. D. Sit in chairs that do not cause her hips to be lower than her knees. Correct answer: B. 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.

8. The nurse is reinforcing general health teaching with a 64 - year-old patient with osteoarthritis (OA) of thehip. Which of the following points would the nurse include in this review of the disorder (select all that apply)?

A. OA cannot be successfully treated with any current therapy options. B. OA is an inflammatory disease of the joints that may present symptoms at any age. C. Joint degeneration with pain and disability occurs in the majority of people by the age of 60.

D. OA is more common with aging, but usually it remains

confined to a few joints and does not cause crippling.

E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication.

Rationale: OA 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. OA can lead to significant disability.

9. When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines thatthe patient needs additional instruction after making which of the following statements?

A. "I should take the Celebrex as prescribed to help control the pain."

B. "I should try to stay standing all day to keep my joints from

becoming stiff."

C. "I can use a cane if I find it helpful in relieving the pressure on my back and hip." D. "A warm shower in the morning will help relieve the stiffness I have when I get up."

Rationale: It is important to maintain a balance between rest and activity to prevent overstressing the joints with OA.

A 60-year-old woman has pain on motion in her fingers and asks the nurse whether this is just a result of aging.

The best response by the nurse includes the information that

a. joint pain with functional limitation is a normal change that affects all people to some extent b. joint pain that develops with age is usually related to previous trauma or infection of the joints c. this is a symptom of a systemic arthritis that eventually affects all joints as the disease progresses

d. changes in the cartilage and bones of joints may cause

symptoms of pain and loss of function in some people as they age

To preserve function and the ability to perform activities of daily living, the nurse teaches the patient with OA to

a. avoid exercise that involves the affected joints

b. plan and organize less stressful ways to perform tasks

c. maintain normal activities during an acute episode to prevent loss of function d. use mild analgesics to control symptoms when performing tasks that cause pain

A patient with OA uses NSAIDs to decrease pain and inflammation. The nurse teaches the patient that common side effects of these drugs include

a. allergic reactions, fever, and oral lesions b. fluid retention, hypertension, and bruising

c. skin rashes, gastric irritation, and headache

d. prolonged bleeding time, blood dyscrasias, and hepatic damage

A patient with OA asks the nurse whether he could try glucosamine and chondroitin for control of his symptoms. The best response by the nurse includes the information that

a. some patients find these supplements helpful for relieving arthritis

knee pain and improving mobility

b. although these substances may not help, there is no evidence that they can cause any untoward effects