Rheumatoid Arthritis and Osteoarthritis: A 25-Year Case Study, Exams of Nursing

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W1 Rheumatic Osteoarthritis

A client diagnosed with osteoarthritis, tells a clinic nurse about the inability to ambulate and staying on bedrest because of hip stiffness. In addition to teaching the client measures to reduce joint stiffness, which referral for the client should the nurse plan to discuss with the health-care provider?

1. Psychiatrist
2. Social worker
3. Physical therapist
4. Arthritis Foundation - ANSWER: 3 The physical therapist can assist the client in adopting self-management strategies and teach isometric, postural, and aerobic exercises that pre- vent joint overuse. A psychiatrist would assist the client in dealing with the mental health aspects related to the disease, such as ineffective coping, loss, or anger. There is no evidence that the client has mental health issues. The social worker would address issues such as finances, home assistance, place- ment, or acquiring assistive devices. The Arthritis Foundation provides a wealth of information to the client, but a referral is not necessary. The client can initiate the contact. ➧ Test-taking Tip: Focus on the issue, joint stiffness, and the health-care specialty that can best assist the client. Content Area: Adult Health; Category of Health Alteration: Musculoskeletal Management; Integrated Processes: Nursing Process Planning; Client Need: Safe and Effective Care Environment/ Management of Care/Referrals; Cognitive Level: Application A nurse is caring for a client with osteoarthritis receiving piroxicam (Feldene®). Which instruction is most important for the nurse to include in the medication teaching plan?
5. "Take the medication with food to decrease gastric irritation."
6. "If your pain is severe, you can take an additional dose of the medication."
7. "Lie down until the medication begins to be effective for pain control."
8. "If you feel you are lacking energy, you can safely take ginkgo for an energy boost." - ANSWER: 1 Piroxicam should be taken with food and a full glass of water to pre- vent gastric irritation and possible bleeding. Piroxicam is administered in a once-daily dose, and additional doses should not be taken. Because of the gastric irritation and possible reflux, the client should sit upright after taking the medication. Ginkgo interacts with piroxicam, increasing the risk for bleeding.

➧ Test-takingTip: Focus on the gastric irritation that occurs with many anti-inflammatory medications. Note that options 1 and 3 address gastric irritation. Eliminate one of these options. Content Area: Adult Health; Category of Health Alteration: Pharmacological and Parenteral Therapies; Integrated Processes: Communication and Documentation; Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies/Medication Administration; Health Promotion and Maintenance/Principles of Teaching and Learning; Cognitive Level: Application Reference: Abrams, A., Lammon, C., & Pennington, S. (2007). Clinical Drug Therapy: Rationales for Nursing Practice (8th ed., pp. 120-121). Philadelphia: Lippincott Williams & Wilkins. To which client should a nurse plan to provide teaching about genetic resources?

1. Client who had an ankle fracture secondary to a boating accident
2. Client who had a ganglion removed from the dorsum of the wrist
3. Client who had a surgical repair of a fracture due to osteoporosis
4. Client who had a total knee replacement due to degenerative joint disease - ANSWER: 3 Genetic factors influence the development of osteoporosis. There is no known genetic link for a ganglion, degenerative joint disease, or accidental fractures (except those due to osteoporosis). ➧ Test-taking Tip: Use the process of elimination to narrow the options to 3 and 4 because these options include secondary causes within the body. Of these two options, eliminate option 4, recalling that degenerative joint disease is caused by osteoarthritis. Content Area: Adult Health; Category of Health Alteration: Musculoskeletal Management; Integrated Processes: Teaching and Learning; Client Need: Safe and Effective Care Environment/Management of Care/Continuity of Care; Cognitive Level: Analysis Reference: Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (11th ed., p. 2345). Philadelphia: Lippincott Williams & Wilkins A 62-year-old female client is attending a community health fair. A health fair nurse recommends that the client make an appointment with a physician and ask that a DEXA (dual-energy x-ray

absorptiometry) scan be done to evaluate for osteoporosis because the client has many risk factors. Which risk factor likely influenced the health fair nurse's decision to recom- mend a DEXA scan?

1. Diabetes mellitus
2. Postmenopausal
3. Overweight
4. African American - ANSWER: 2 Major risk factors for osteoporosis include increased age, female sex, White or Asian race, family history of osteoporosis, and a thin body structure. Since osteoporosis is the most common metabolic disease, affecting 50% of women during their lifetime, it is important for women to be screened and begin appropriate treatment, if needed. Diabetes mellitus and being overweight are not risk factors for osteoporo- sis. Being overweight can contribute to the development of osteoarthritis. ➧Test-takingTip:Focusonwhatthequestionisasking:risk factors of osteoporosis. Content Area: Adult Health; Category of Health Alteration: Older Client Needs; Integrated Processes: Nursing Process Evaluation; Client Need: Health Promotion and Maintenance/Health Screening; Cognitive Level: Application Reference: Tabloski, P. (2006). Gerontological Nursing (p. 557). Upper Saddle River, NJ: Pearson/Prentice Hall.
5. An older client with osteoarthritis is taking celecoxib (Celebrex®). After reviewing the client's laboratory values for the past 3 months, what should be a clinic nurse's priority when assessing the client? Serum Laboratory Test BUN Creatinine 6 Months Ago 13 mg/dL 0.8 mg/dL 3 Months Ago 19 mg/dL 1.2 mg/dL Today 28 mg/dL 1.8 mg/dL

1. Review urinalysis results
2. Measure the client's blood pressure
3. Ask the client if there has been any weight gain
4. Auscultate the client's heart sounds - ANSWER: 2 Adverse effects of long-term use of Cox-2 inhibitors include renal impairment, which can be manifested by edema and elevated blood pressure. The progressive elevation of the serum creatinine and blood urea nitrogen suggest renal impairment. The urinalysis provides additional information, but is not the priority. Weight measurement and auscultation of the heart are part of normal health assessment. ➧ Test-taking Tip: Note the key word "priority." Apply knowledge of the adverse effects of celecoxib to answer this question. Content Area: Management of Care; Category of Health Alteration: Prioritization and Delegation; Integrated Processes: Nursing Process Assessment; Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications; Cognitive Level: Analysis Reference: Abrams, A., Lammon, C., & Pennington, S. (2007). Clinical Drug Therapy: Rationales for Nursing Practice (8th ed., p. 108). Philadelphia: Lippincott Williams & Wilkins. A client is diagnosed with degenerative joint dis- ease of the left knee, which is to be treated conserva- tively. A nurse should include which information when planning teaching for the client? SELECT ALL THAT APPLY.
5. Begin a progressive walking program
6. Modify diet for weight reduction
7. Apply cold or heat to the knee joint
8. Obtain a prescription for narcotic analgesics for pain control
9. Avoid prolonged standing, kneeling, squatting, and stair climbing

6. Perform vigorous activities daily, such as rapid flexion and extension of the knee - ANSWER: 1, 2, 3, 5 Progressive walking strengthens bone and muscles and helps reduce obesity. Walking should be for a duration that is well tolerated initially and then walking is gradually increased to a duration of 30- minutes 5 to 7 days per week. Weight reduction decreases stress on the joints. Cold will reduce swelling and inflammation; heat increases circulation to the area and increases comfort. Avoiding prolonged standing, kneel- ing, squatting, and stair climbing will protect the knee joint. First-line medications include acetaminophen (Tylenol®) or, if not effective, a nons- teroidal anti-inflammatory drug (NSAID). Vigorous activities that produce prolonged pain and inflammation should be avoided because these stress the joint. ➧ Test-taking Tip: Focus on initial measures to protect the knee joint, reduce pain, and increase activity tolerance. Content Area: Adult Health; Category of Health Alteration: Musculoskeletal Management; Integrated Processes: Nursing Process Planning; Client Need: Physiological Integrity/Physiological Adaptation/ Illness Management; Cognitive Level: Application Reference: Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (11th ed., pp. 1914-1917). Philadelphia: Lippincott Williams & Wilkins. EBP Reference: American Academy of Orthopaedic Surgeons (AAOS). (2008). Treatment of osteoarthritis of the knee (non-arthroplasty). Rosemont (IL): AAOS. Available at: www.guideline.gov/summary/ summary.aspx?doc_id=14279&nbr=
7. The client diagnosed with RA is being seen in the outpatient clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits?
8. Perform joint x-rays to determine progression of the disease. 2.Send blood to the laboratory for an erythrocyte sedimentation rate. 3.Recommend the flu and pneumonia vaccines.
9. Assess the client for increasing joint involvement. -
   1. This is done, but it will not prevent any disease from occurring.
10. This will follow the progression of the disease of RA, but it is not preventive. **3. RA is a disease with many immunological abnormalities. The clients have increased susceptibility to infectious disease, suchas the flu or pneumonia, and, therefore, vaccines, which are preventive, should be recommended.

4. Assessing the client does not address preven- tive care. TEST-TAKING HINT: The stem requires the test taker to determine what action is pre- ventive care for the client with RA. Only option "3" addresses preventive care. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Application: Concept - Immunity. chapter 13 IMMUNE SYSTEM DISorderS
5. The client with RA has nontender, movable nodules in the subcutaneous tissue over the elbows and shoulders. Which statement is the scientific rationale for the nodules?
6. The nodules indicate a rapidly progressive destruction of the affected tissue.
7. The nodules are small amounts of synovial fluid that have become crystallized.
8. The nodules are lymph nodes which have proliferated to try to fight the disease.
9. The nodules present a favorable prognosis and mean the client is better. - **1. The nodules may appear over bony promi- nences and resolve simultaneously. They appear in clients with the rheumatoid factor and are associated with rapidly progressive and destructive disease.
10. There is a proliferation of the synovial mem- brane in RA, which leads to the formation of pannus and the destruction of cartilage and bone, but synovial fluid does not crystallize to form the nodules.
11. The nodules are not lymph nodes. Lymph nodes may enlarge in the presence of disease, but they do not proliferate (multiply).
12. The nodes indicate a progression of the disease, not an improving prognosis TEST-TAKING HINT: The test taker can rule out option "3" with knowledge of anatomyor physiology. Lymph nodes do not multiply; they do form chains throughout the body. Content - Medical: Integrated Nursing Process - Diagnosis: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Comprehension: Concept - Immunity.chapter 13 IMMUNE SYSTEM DISorderS
13. The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention?
14. The client complains of joint stiffness and the

knees feel warm to the touch.

2. The client has experienced one (1)-kg weight loss and is very tired .3. The client requires a heating pad applied to the hips and back to sleep.
3. The client is crying, has a flat facial affect, and refuses to speak to the nurse. - 1.Joint stiffness and joints warm to the touch
4. Clients diagnosed with RA have bilateral and symmetrical stiffness, edema, tenderness, and temperature changes in the joints. Other symptoms include sensory changes, lymph node enlargement, weight loss, fatigue, and pain. A one (1)-kg weight loss and fatigue are expected.
5. The use of heat is encouraged to provide comfort for a client diagnosed with RA. **4 The client has the signs and symptoms of depression. The nurse should attempt to intervene with therapeutic conversation and discuss these findings with the HCP TEST-TAKING HINT: The test taker should not automatically assume only physiological data require immediate intervention. There will be times when a psychological need will have priority. Because options "1," "2," and "3" are all expected in a client with RA, the psy- chological need warrants intervention by the nurse. Content - Medical: Integrated Nursing Process - Assessment: Client Needs - Physiological Integrity, Reduction of Risk Potential: Cognitive Level - Synthesis: Concept - Mood. chapter 13 IMMUNE SYSTEM DISorderS
6. The client diagnosed with RA who has been prescribed etanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach?
7. Explain the medication loses its efficacy after a few months.

2. Continue to have checkups and laboratory work while taking the medication.
3. Have yearly magnetic resonance imaging to follow the progress.
4. Discuss the drug is taken for three (3) weeks and then stopped for a week. -
   1. The drug does not lose efficacy, and clients are removed from the drug when the body cannot tolerate the side effects. **2. The drug requires close monitoring to prevent organ damage.
5. MRI scans are not used to determine the progress of RA.
6. There is no "off" period for the drug. TEST-TAKING HINT: If the test taker is not aware of the medication being discussed, option "2," the correct answer, is information which could be said of most medications. Content - Medical: Integrated Nursing Process - Planning: Client Needs - Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level - Synthesis: Concept - Medication. chapter 13 IMMUNE SYSTEM DISorderS
7. The client diagnosed with RA has developed swan-neck fingers. Which referral is most appropriate for the client?
8. Physical therapy.
9. Occupational therapy.
10. Psychiatric counselor.
11. Home health nurse. -
    1. Physical therapists work with gait training and muscle strengthening. Generally, the physical therapist works on the lower half of the body. ✅*2. The occupational therapist assists the client in the use of the upper half of the body, fine motor skills, and activities of daily living. This is needed for the client with abnormal fingers.

3. A counselor can help the client discuss feelings about body image, loss of function, and role changes, but the best referral is to the occupational therapist.
4. The client may need a home health nurse eventually, but first the client should be assisted to remain as functional as possible TEST-TAKING HINT: The test taker must be aware of the roles of all the health-care team members. The counselor (option "3") canbe ruled out as a possible correct answer because swan-neck fingers are a physical problem. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Application: Concept - Immunity. chapter 13 IMMUNE SYSTEM DISorderS
5. The nurse is planning the care for a client diagnosed with RA. Which intervention should be implemented?
6. Plan a strenuous exercise program.
7. Order a mechanical soft diet.
8. Maintain a keep-open IV.
9. Obtain an order for a sedative. - .1.The client diagnosed with RA is generally fatigued, and strenuous exercise increases the fatigue, places increased pressure on the joints, and increases pain.
10. The client should be on a balanced diet high in protein, vitamins, and iron for tissue building and repair and should not require a mechanically altered diet.
11. There is no specific reason for the client to be ordered a keep-open IV; the client can swallow needed medications. ✅4. Sleep deprivation resulting from pain is common in clients diagnosed with RA.A mild sedative can increase the client's ability to sleep, promote rest, and increase the client's tolerance of pain. TEST-TAKING HINT: The test taker should be aware of adjectives leading to an option being eliminated—for example, the word "strenuous" in option "1."

Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Application: Concept - Comfort. chapter 13 IMMUNE SYSTEM DISorderS

79. The 20-year-old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications?
80. "Are you sexually active, and, if so, are you using birth control?"
81. "Have you discussed taking these drugs with your parents?"
82. "Which arm do you prefer to have an IV in for four (4) days?"
83. "Have you signed an informed consent for investigational drugs?" - ✅1. Immunosuppressive medications are considered class C drugs and should not be taken while pregnant. These drugs are teratogenic and carcinogenic, and the client is only 20 years old.
84. Any individual older than age 18 years is con- sidered an adult and does not need to discuss treatment with her parents unless she chooses to do so.
85. The medications can be administered on an outpatient basis, but if an inpatient has in- travenous therapy, then IV sites are changed every 72 hours and there is no guarantee an IV will last for four (4) days.
86. These are not investigational drugs and are standard therapy approved by the American College of Rheumatology and the Food and Drug Administration. TEST-TAKING HINT: The age of the client and the fact the client is female could give the test taker an idea of the correct answer. This is a client in the childbearing years. Content - Medical: Integrated Nursing Process - Assessment: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Analysis: Concept - Medication.

chapter 13 IMMUNE SYSTEM DISorderS

80. Which client problem is priority for a client diagnosed with RA?
81. Activity intolerance.
82. Fluid and electrolyte imbalance.
83. Alteration in comfort.
84. Excessive nutritional intake. -
    1. Activity intolerance is an appropriate client problem, but it is not priority over pain.
85. The client with RA does not experience fluid and electrolyte disturbance. ✅3. The client diagnosed with RA has chronic pain; therefore, alteration in comfort is a priority problem.
86. Clients diagnosed with RA usually experience anorexia and weight loss, unless they are tak- ing long-term steroids. TEST-TAKING HINT: The question is asking for the priority problem, and pain is priority according to Maslow's hierarchy of needs. Content - Medical: Integrated Nursing Process - Diagnosis: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Analysis:Concept - Comfort. chapter 13 IMMUNE SYSTEM DISorderS
87. The nurse is caring for clients on a medical floor. Which client should the nurse assess first?
88. The client diagnosed with RA complaining of pain at a "3" on a 1-to-10 scale.
89. The client diagnosed with SLE who has a rash across the bridge of the nose.
90. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV.
91. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes. -
    1. The client in pain should receive medication as soon as possible to keep the pain from be- coming worse, but the client is not at risk for a serious complication

2.A butterfly rash across the bridge of the nose occurs in approximately 50% of the clients diagnosed with SLE. ✅3. Antineoplastic drugs can be caustic to tis- sues; therefore, the client's IV site should be assessed. The client should be assessed for any untoward reactions to the medica- tions first.

4. Scleroderma is a disease characterized by waxlike skin covering the entire body. This is expected for this client TEST-TAKING HINT: Pain is a priority, but the test taker must determine if there is another client who could experience complications if not seen immediately. Content - Medical: Integrated Process - Assessment: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Synthesis: Concept - Immunity. chapter 13 IMMune SySteM dISorderS
5. The nurse and a licensed practical nurse are caring for clients in a rheumatologist's office. Which task can the nurse assign to the licensed practical nurse?
6. Administer methotrexate, an antineoplastic medication, IV.
7. Assess the lung sounds of a client with RA who is coughing.
8. Demonstrate how to use clothing equipped with Velcro fasteners.
9. Discuss methods of birth control compatible with treatment medications. -
   1. Antineoplastic medications can be adminis- tered only by a registered nurse who has been trained in the administration and disposal of these medications.
10. Assessment cannot be assigned to a licensed practical nurse. **3. The licensed practical nurse (LPN) can demonstrate how to use adaptive clothing.
11. This is teaching requiring knowledge of medications and interactio TEST-TAKING HINT: The nurse cannot assign assessment, evaluation, or teaching or any medication requiring specialized knowledge or skills to administer safely.

Content - Medical: Integrated Nursing Process - Planning: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Synthesis: Concept - Nursing Roles.

83. The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instruction should the nurse teach regarding the use of nonsteroidal anti- inflammatory drugs (NSAIDs)?
84. Take with an over-the-counter medication for the stomach.
85. Drink a full glass of water with each pill.
86. If a dose is missed, double the medication at the next dosing time.
87. Avoid taking the NSAID on an empty stomach. -
    1. This is prescribing, and the nurse is not licensed to do this unless the nurse has become a nurse practitioner.
88. NSAIDs do not require a specific amount of water to be effective, unlike bulk laxatives.
89. The medication should be taken in the usual dose when the client realizes a dose has been missed. ✅*4. NSAID medications decrease prostaglandin production in the stomach, resulting in less mucus production, which creates a risk for the development of ulcers. The client should take the NSAID with food. TEST-TAKING HINT: Knowledge of medication administration is a priority for every nurse. It is especially important for the nurse to be familiar with commonly used medications such as NSAIDs, which can be purchased over the counter and may be taken by the client in addition to prescription medications. Content - Medical: Integrated Nursing Process - Planning: Client Needs - Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level - Synthesis: Concept - Medication.
90. The nurse is preparing to administer morning medications. Which medication should the nurse administer first?
91. The pain medication to a client diagnosed with RA.

2. The diuretic medication to a client diagnosed with SLE.
3. The steroid to a client diagnosed with polymyositis .4. The appetite stimulant to a client diagnosed with OA. - ✅1. Pain medication is important and should be given before the client's pain becomes worse.
4. Unless the client is in a crisis, such as pulmo- nary edema, this medication can wait.
5. Steroids do not have precedent over pain medication and should be administered with food.
6. Clients diagnosed with OA are usually overweight and do not require appetite stimulants. The nurse should question this medication before administering the medication. TEST-TAKING HINT: When determining priorities, the test taker must employ some criteria to use as a guideline. According to Maslow, pain is a priority. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Application: Concept - Medication. Cyclosporine (Sandimmune®) and methotrexate (Rheumatrex®) are prescribed for a client with severe rheumatoid arthritis. Which points should a nurse address when teaching the client about these medications? SELECT ALL THAT APPLY.
7. Drinking grapefruit juice is best because the medications' effects are enhanced.
8. Keep well hydrated to maximize the therapeutic effects of methotrexate.
9. Avoid use of St. John's wort, echinacea, and melatonin, as these may interfere with immunosuppression.
10. These medications are administered weekly by subcutaneous injection.

5. Both methotrexate and cyclosporine suppress the immune system. - ANSWER: 2, 3, 5 Adequate hydration minimizes the risk of adverse effects. St. John's wort decreases cyclosporine levels. Echinacea and melatonin interact with cyclosporine to alter immunosuppression. Methotrexate and cy- closporine both have immunosuppressive effects. Grapefruit juice should be avoided because it can increase the concentration of cyclosporine. Methotrexate and cyclosporine can be taken orally instead of by injection. It is incorrect that both medications are taken weekly. Only methotrexate is taken weekly, whereas cyclosporine is usually taken twice daily. ➧ Test-taking Tip: Read each option carefully and apply knowledge of the immunosuppressant medications to answer this question. Content Area: Adult Health; Category of Health Alteration: Pharmacological and Parenteral Therapies; Integrated Processes: Teaching and Learning; Client Need: Physiological Integrity/ Pharmacological and Parenteral Therapies/Pharmacological Interactions; Cognitive Level: Analysis References: Aschenbrenner, D., & Venable, S. (2009). Drug Therapy in Nursing (3rd ed., pp. 432-436). Philadelphia: Lippincott Williams & Wilkins; Wilson, B., Shannon, M., Shields, K., & Stang, C. (2008). Prentice Hall Nurse's Drug Guide 2008 (pp. 397-400, 967-970). Upper Saddle River, NJ: Pearson Education. 2 of 16 The nurse is caring for a client with osteoarthritis (OA) in the left knee. What factor does the nurse suspect is the most likely cause of this client's OA? Trauma to the joint Aging Osteoporosis Familial history - ✅Trauma to the joint The client has OA in one knee which suggests that the client has secondary OA rather than primary disease. Secondary OA occurs as a result of joint injury or obesity Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

1 of 16 The nurse is developing a health teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? Take up knitting to slow down joint degeneration. Eat at least 2 yogurts every day. Wear supportive shoes at all times. Begin a jogging or running program. - ✅Wear supportive shoes at all times. Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints. Running and running promotes stress on joints and should be avoided. Repetitive stress activities such as knitting or typing should be avoided for prolonged periods. No single food can cure OA; a well-balanced diet should be recommended. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 3 of 16 The nurse is caring for a client with an inflamed, reddened, and severely painful first metatarsal joint. With what type of arthritis are these signs and symptoms associated? Rheumatoid arthritis Infectious arthritis Gouty arthritis Osteoarthritis -

✅Gouty arthritis Clients who have gout (also called gouty arthritis) experience severe inflammation in small joints, especially the metatarsal of the great (first) toe. Gout results when urate crystals created by errors in purine metabolism deposit in small synovial joints Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 4 of 16 The nurse is assessing an older client who has bony nodules on finger joints (Heberden and Bouchard nodes). What priority question would the nurse want to ask as part of the client interview? "When did your bony nodules develop?" "How do you feel about having these bony nodules?" "Are you able to independently perform ADLs?" "Are your bony nodules painful or tender? - ✅"Are you able to independently perform ADLs?" As a result of the client having bony nodules in his or her hands, the most important question for the nurse to ask is to determine if the client is ADL independent. The nurse would also ask the other questions, but they are not the first questions to be asked. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 5 of 16 A client was recently diagnosed with osteoarthritis and asks the nurse which over-the-counter drug would be the best to take? What would the nurse's recommendation be? Ibuprofen

Acetaminophen Tramadol Gabapentin - ✅Acetaminophen Several major medical organizations, including the American Pain Society and OARSI committee recommend acetaminophen as the primary drug of choice. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 6 of 16 The nurse is caring for a client with osteoarthritis who reports severe pain in both knees. What nonpharmacologic intervention is the most appropriate for the nurse to recommend for this client? Massage and hypnosis. Hot compresses or moist heating pad. Glucosamine and chondroitin combination. Ice packs used every 3 to 4 hours during the day. - ✅Glucosamine and chondroitin combination. Heat sources such as compresses and heating pads cause vasodilation which promotes healing in the affected joints. Ice is best for inflamed joints rather than those that are degenerative. Glucosamine and chondroitin are integrative therapies that help some clients but their effectiveness has not been validated. Massage would be painful and hypnosis may or may not be helpful, depending on the client. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

7 of 16 The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? "I do not know how long my wife will be able to take care of me at home." "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." "I do not know how much longer my neighbor can continue to help clean my house." "The bus is coming to pick me up from the senior center three times a week so I can play cards." - ✅"The bus is coming to pick me up from the senior center three times a week so I can play cards." Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support. Caregiving responsibilities can be a source of stress; the client worrying about his wife's caregiving abilities does not indicate that the client is effectively coping. Routine tasks, such as doing dishes and laundry, need to be reassigned or effective pain management should be instituted before activities are undertaken to demonstrate effective coping. Neighbors are not reliable resources for in-home needs, and asking a neighbor to help does not indicate that the client is coping effectively. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 8 of 16 The nurse assesses a client diagnosed with Sjögren syndrome. The nurse anticipates that the client will also have which symptom? Excessive production of saliva in the mouth Intermittent episodes of diarrhea Abdominal bloating after eating

Dry eyes - ✅Dry eyes Clients with Sjögren syndrome experience dry eyes (keratoconjunctivitis sicca), dry mouth, and if female, dry vagina. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 9 of 16 The nurse is preparing a client for a total hip arthroplasty today. What IV antibiotic would the nurse likely administer if the client has no drug allergies? Penicillin Clindamycin Vancomycin Cefazolin - ✅Cefazolin Cephalosporins are the drug class of choice for clients without allergies who are having a total joint arthroplasty. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 10 of 16 The nurse is preparing to give apixaban for a client who recently had a total knee arthroplasty. What does the nurse recognize as the advantage of this drug over other anticoagulants? The client does not need to have labs drawn for PT or INR.

The client only needs to take the drug while in the hospital. The client is not at risk for bleeding or bruising. The client does not need to wear sequential compression devices. - ✅The client does not need to have labs drawn for PT or INR. Apixaban is a newer factor Xa inhibitor that helps to prevent venous thromboembolism in clients who have a total knee arthroplasty. The client taking this drug will need to continue for several weeks after surgery and is at risk for bleeding or bruising. However, the drug does not affect PT or INR, so that the client does not need to have labs drawn. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 11 of 16 The nurse is caring for a client who has a continuous femoral nerve blockade following a total knee arthroplasty. What nursing assessment does the nurse need to perform to ensure client safety? Monitor vital signs frequently to detect early complications. Perform focused cardiovascular and respiratory assessments. Check that the client can dorsiflex and plantar flex the foot on the operative leg. Monitor for excessive blooding and bruising during the infusion. - ✅Check that the client can dorsiflex and plantar flex the foot on the operative leg. To ensure that the client is not receiving excessive anesthesia, the client should be able to dorsiflex and plantar flex the foot on the operative leg. The purpose of the continuous femoral nerve blockade is to help control postoperative pain Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty

12 of 16 The nurse has provided health teaching for a female client starting on methotrexate (MTX) for early rheumatoid arthritis. What statement by the client indicates a need for further teaching? "I will try to avoid crowds because I could easily get an infection." "I will start folic acid supplements whichh can help decrease side effects." "I can drink alcohol in small amounts at night to help me relax." "I will use strict birth control while I am taking this drug." - ✅"I can drink alcohol in small amounts at night to help me relax." All of these statements are correct about MTX except that the client needs to avoid all alcoholic beverages to prevent liver toxicity. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 13 of 16 The nurse is planning health teaching for a client starting hydroxychloroquine for rheumatoid arthritis. What instruction would the nurse include in the teaching? "Be aware that the drug may cause secondary types of cancer." "Expect nausea and vomiting for the first week after starting the drug." "Have eye examinations every 6 months while on the drug." "Keep this medication in the refrigerator at all times." - ✅"Have eye examinations every 6 months while on the drug."

Hydroxychloroquine is an antimalarial drug with immune modulating and anti-inflammatory properties. Although side effects are usually mild, long-term use of the drug can cause vision problems. The client is taught to have an eye examination prior to starting the drug and every 6 months while on the drug to detect any visual changes. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 14 of 16 The nurse is caring for a postoperative client with total hip arthroplasty. What actions would the nurse take to prevent venous thromboembolism (VTE) postoperatively? (Select all that apply.) Select all that apply. Apply pneumatic or sequential compression devices. Administer anticoagulant therapy. Ambulate the client on the day of surgery. Elevate the client's legs. Keep the legs slightly abducted. - ✅Apply pneumatic or sequential compression devices. ✅Administer anticoagulant therapy. ✅Ambulate the client on the day of surgery. Preventive postoperative actions that help prevent VTE include pharmacology (anticoagulants), ambulation, and compression. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 15 of 16

The nurse recognizes that a client who has persistent pain may have difficulty with pain management after a total joint arthroplasty. What collaborative interventions are needed to help the client manage postoperative pain? (Select all that apply.) Select all that apply. Establish trust and explain the postoperative pain management plan. Consult the pain management team if needed and available. Plan continuing pain management after discharge. Use multimodal and alternative pain management modalities. Identify at-risk clients preoperatively using a comprehensive assessment. - ✅CORRECT Establish trust and explain the postoperative pain management plan. All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain. CORRECT Consult the pain management team if needed and available. All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain. CORRECT Plan continuing pain management after discharge. All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain. CORRECT Use multimodal and alternative pain management modalities. All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain. CORRECT Identify at-risk clients preoperatively using a comprehensive assessment.

All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain. Chapter 46 - Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty 16 of 16 The nurse is teaching a client preparing to have a total knee replacement about interventions to help prevent surgical infection. What interventions would the nurse include in this teaching? (Select all that apply.) Select all that apply. Using nasal mupirocin for at least a week before surgery Avoiding sleeping with pets in the client's bed Showering the night before and the morning of surgery with chlorhexidine Giving antibiotics before and after surgery for at least 3 days Sleeping on clean linen wearing clean nightwear - ✅Using nasal mupirocin for at least a week before surgery All of these interventions are used to help prevent infection except for the use of long-term antibiotics. Long-term antibiotic therapy is used to treat rather than prevent postoperative infection. ✅Avoiding sleeping with pets in the client's bed All of these interventions are used to help prevent infection except for the use of long-term antibiotics. Long-term antibiotic therapy is used to treat rather than prevent postoperative infection. ✅Showering the night before and the morning of surgery with chlorhexidine ✅Sleeping on clean linen wearing clean nightwear