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Chapter 64: Arthritis and Connective Tissue Diseases Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of

the knee? Presence of Heberden’s nodules Discomfort with joint movement Redness and swelling of the knee joint Stiffness that increases with movement

a. b. c. d.

ANS: B

Initial symptoms of OA include pain with joint movement. Heberden’s nodules occur on the fingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests and decreases with joint movement. DIF: Cognitive Level: Understand (comprehension) REF: 1518 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is

likely to require a change in medication? The patient has gained 3 lb. The patient has dark-colored stools. The patient’s pain affects multiple joints. The patient uses capsaicin cream (Zostrix).

a. b. c. d.

ANS: B

Dark-colored stools may indicate the patient is experiencing gastrointestinal bleeding caused by the naproxen. The patient’s ongoing pain and weight gain will also be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate. DIF: Cognitive Level: Apply (application) REF: 1521 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about

how to manage the OA, which patient statement indicates a need for more teaching? “I can exercise every day to help maintain joint motion.” “I will take 1 g of acetaminophen (Tylenol) every 4 hours.” “I will take a shower in the morning to help relieve stiffness.” “I can use a cane to decrease the pressure and pain in my hip.”

a. b. c. d.

ANS: B

No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease the risk for liver damage. Regular exercise, moist heat, and supportive equipment are recommended for OA management.

DIF: Cognitive Level: Apply (application) REF: 1523 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 4. The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which

medication? a. Prednisone b. Adalimumab (Humira)

c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

ANS: C

Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with rheumatoid arthritis. DIF: Cognitive Level: Apply (application) REF: 1520 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the

nurse take? Draw blood for rheumatoid factor analysis. Teach the patient about injections for the nodules. Assess the nodules for skin breakdown or infection. Discuss the need for surgical removal of the nodules.

a. b. c. d.

ANS: C

Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence. DIF: Cognitive Level: Apply (application) REF: 1527 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 6. Which action will the nurse include in the plan of care for a patient with a new diagnosis of

rheumatoid arthritis (RA)? Instruct the patient to purchase a soft mattress. Encourage the patient to take a nap in the afternoon. Teach the patient to use lukewarm water when bathing. Suggest exercise with light weights several times daily.

a. b. c. d.

ANS: B

Adequate rest helps decrease the fatigue and pain associated with RA. Patients are taught to avoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When the disease is stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve flexibility and strength of affected joints, as well as the patient’s general endurance. DIF: Cognitive Level: Apply (application) REF: 1531 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having

chronically dry eyes. Which action by the nurse is appropriate? a. Ask the HCP about discontinuing methotrexate b. Remind the patient that RA is a chronic health condition. c. Suggest the patient use over-the-counter (OTC) artificial tears.

d. Teach the patient about adverse effects of the RA medications. ANS: C

The patient’s dry eyes are consistent with Sjögren’s syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. A focus on the prognosis for RA is not helpful. The dry eyes are not caused by RA treatment but by the disease itself. DIF: Cognitive Level: Apply (application) REF: 1546 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. Which information will the nurse include when preparing teaching materials for a patient with

an exacerbation of rheumatoid arthritis? Affected joints should not be exercised when pain is present. Applying cold packs before exercise may decrease joint pain. Exercises should be performed passively by someone other than the patient. Walking may substitute for range-of-motion (ROM) exercises on some days.

a. b. c. d.

ANS: B

Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises. DIF: Cognitive Level: Apply (application) REF: 1531 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. Which laboratory result will the nurse monitor to determine if prednisone has been effective

for a patient with an acute exacerbation of rheumatoid arthritis? c. Serum electrolytes d. Liver function tests

a. Blood glucose b. C-reactive protein ANS: B

C-reactive protein is a serum marker for inflammation, and a decrease would indicate the corticosteroid therapy was effective. Blood glucose and serum electrolytes will also be monitored to assess for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids. DIF: Cognitive Level: Apply (application) REF: 1527 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 10. The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to

manage activities of daily living suggests they should avoid activities requiring repetitive use of the same muscles and joints. protect the knee joints by sleeping with a small pillow under the knees. stand rather than sit when performing daily household and yard chores. strengthen small hand muscles by wringing out sponges or washcloths.

a. b. c. d.

ANS: A

Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase joint stress. Patients are encouraged to position joints in the extended (neutral) position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion. DIF: Cognitive Level: Apply (application) REF: 1524 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to

start each day with a brief routine of isometric exercises. a warm bath followed by a short rest. active range-of-motion (ROM) exercises. stretching exercises to relieve joint stiffness.

a. b. c. d.

ANS: B

Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased. DIF: Cognitive Level: Apply (application) REF: 1531 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). When teaching

the patient about this drug, the nurse will include information about avoiding concurrent aspirin use. symptoms of gastrointestinal (GI) bleeding. self-administration of subcutaneous injections. taking the medication with at least 8 oz of fluid.

a. b. c. d.

ANS: C

Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued. DIF: Cognitive Level: Apply (application) REF: 1529 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. A patient with two school-age children has recently been diagnosed with rheumatoid arthritis

(RA) and tells the nurse that home life is very stressful. Which initial response by the nurse is most appropriate? a. “You need to see a family therapist for some help with stress.” b. “Tell me more about the situations that are causing you stress.” c. “Your family should understand the impact of your rheumatoid arthritis.” d. “Perhaps it would be helpful for your family to be involved in a support group.” ANS: B

The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

DIF: Cognitive Level: Analyze (analysis) REF: 1532 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 14. Which information will the nurse include when teaching a patient with newly diagnosed

ankylosing spondylitis (AS) about management of the condition? Exercise by taking long walks. Do daily deep-breathing exercises. Sleep on the side with hips flexed. Take frequent naps during the day.

a. b. c. d.

ANS: B

Deep-breathing exercises are used to decrease the risk for pulmonary complications that may result from reduced chest expansion that can occur with AS. Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps. DIF: Cognitive Level: Apply (application) REF: 1537 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 15. A patient hospitalized with a fever and red, hot, painful knees is suspected of having septic

arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. had several knee injuries as a teenager. b. recently returned from South America. c. is sexually active with multiple partners. d. has a parent who has rheumatoid arthritis. ANS: C

Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis. DIF: Cognitive Level: Understand (comprehension) REF: 1535 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse notices a circular lesion with a red border and clear center on the arm of a summer

camp counselor who is in the clinic complaining of chills and muscle aches. Which action should the nurse take to follow up on that finding? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history. ANS: C

The patient’s clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient’s symptoms do not suggest cardiac or abdominal problems or lack of immunization. DIF: Cognitive Level: Apply (application) REF: 1534 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 17. A patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The

nurse will plan to teach the patient about the need for several months of therapy with

a. methotrexate b. anakinra (Kineret).

c. etanercept (Enbrel). d. doxycycline (Vibramycin).

ANS: D

Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis. DIF: Cognitive Level: Apply (application) REF: 1538 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. The nurse determines that colchicine has been effective for a patient with an acute attack of

gout upon finding a. reduced joint pain. b. increased urine output.

c. elevated serum uric acid. d. increased white blood cells (WBC).

ANS: A

Colchicine reduces joint pain in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day during acute gout would increase urine output but would not indicate the effectiveness of colchicine. Elevated serum uric acid would result in increased symptoms. The WBC count might decrease with decreased inflammation but would not increase. DIF: Cognitive Level: Understand (comprehension) REF: 1533 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 19. A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The

nurse will plan to monitor a. blood glucose. b. blood pressure.

c. erythrocyte count. d. lymphocyte count.

ANS: B

Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes. DIF: Cognitive Level: Apply (application) REF: 1534 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 20. A patient who takes multiple medications develops acute gouty arthritis. The nurse will

consult with the health care provider before giving the prescribed dose of sertraline (Zoloft). famotidine (Pepcid). hydrochlorothiazide. oxycodone (Roxicodone).

a. b. c. d.

ANS: A

Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer. DIF: Cognitive Level: Apply (application) REF: 1532 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

21. Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient

has understood the nurse’s teaching about the condition? “I will exercise even if I am tired.” “I will use sunscreen when I am outside.” “I should avoid nonsteroidal antiinflammatory drugs.” “I should take birth control pills to avoid getting pregnant.”

a. b. c. d.

ANS: B

Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE. DIF: Cognitive Level: Apply (application) REF: 1542 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 22. A 25-yr-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and

alopecia tells the nurse, “I never leave my house because I hate the way I look.” The nurse will plan interventions with the patient to address the nursing diagnosis of a. social isolation. c. impaired skin integrity. b. activity intolerance. d. impaired social interaction. ANS: A

The patient’s statement about not going anywhere because of hating the way he or she looks expresses social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient. DIF: Cognitive Level: Apply (application) REF: 1542 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 23. A new clinic patient with joint swelling and pain is being tested for systemic lupus

erythematosus. Which test will provide the most specific findings for the nurse to review? Rheumatoid factor (RF) Antinuclear antibody (ANA) Anti-Smith antibody (Anti-Sm) Lupus erythematosus (LE) cell prep

a. b. c. d.

ANS: C

The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE. DIF: Cognitive Level: Apply (application) REF: 1540 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 24. The nurse is planning care for a patient with hypertension and gout who has a red, painful

right great toe. Which nursing action will be included in the plan of care? Gently palpate the toe to assess swelling. Use pillows to keep the right foot elevated. Use a footboard to hold bedding away from the toe. Teach the patient to avoid use of acetaminophen (Tylenol).

a. b. c. d.

ANS: C

Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe, and touching the toe should be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain management. DIF: Cognitive Level: Understand (comprehension) REF: 1534 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 25. The health care provider has prescribed the following interventions for a patient who is taking

azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. c. Naproxen (Aleve) 200 mg BID. b. Administer varicella vaccine. d. Famotidine (Pepcid) 20 mg daily. ANS: B

Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient. DIF: Cognitive Level: Apply (application) REF: 1540 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 26. A patient has scleroderma manifested by CREST (calcinosis, Raynaud’s phenomenon,

esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep the environment warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake. ANS: B

Keeping the room warm will decrease the incidence of Raynaud’s phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose or to assist the patient to the bath...