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Med/surg - Chapter 67: Nursing Management: Arthritis and Connective Tissue Diseases
Terms in this set (42)
1. Which of the following findings should the nurse expect when assessing an older-adult
client who has osteoarthritis (OA) of the left knee?
a. Heberden nodules
b. Pain upon joint movement
c. Redness and swelling of the knee joint
d. Stiffness that increases with movement
Initial symptoms of OA include pain with joint movement. Heberden nodules occur on the
fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA),
and stiffness in OA is worse right after the client rests and decreases with joint movement.
2. Which of the following assessment findings about a client who has been using naproxen
for 3 weeks to treat osteoarthritis is most important for the nurse to report to the health
a. The client has dark-coloured stools.
b. The client's pain has not improved.
c. The client is using capsaicin cream.
d. The client has gained 3 pounds over 3 weeks.
Dark-coloured stools may indicate that the client is experiencing gastrointestinal bleeding
caused by the naproxen. The information about the client's ongoing pain and weight gain
also will be reported and may indicate a need for a different treatment or counselling 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.
3. The nurse is teaching a client with osteoarthritis (OA) of the left hip and knee about how
to manage the OA. Which of the following client statements indicates a need for more
a. "I can take glucosamine to help decrease my knee pain."
b. "I will take 1 g of acetaminophen every 4 hours."
c. "I will take a shower in the morning to help relieve stiffness."
d. "I can use a cane to decrease the pressure and pain in my hip."
No more than 4 g of acetaminophen should be taken daily to avoid liver toxicity. The other
client statements are correct and indicate good understanding of OA management.
4. The nurse is planning care for a client who has osteoarthritis. Which of the following
medications should the nurse anticipate being prescribed for the client?
c. Capsaicin cream
Capsaicin cream blocks the transmission of pain impulses and is helpful for some clients
in treating OA. The other medications would be used for clients with RA.
5. A client who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes
that rheumatoid nodules are present on the client's elbows. Which of the following actions
should the nurse take?
a. Draw blood for rheumatoid factor analysis.
b. Teach the client about injection of the nodule.
c. Assess the nodules for skin breakdown or infection.
d. Discuss the need for surgical removal of the nodule.
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.
6. The nurse is caring for a client with a new diagnosis of rheumatoid arthritis. Which of the
following actions should the nurse include in the plan of care?
a. Instruct the client to purchase a soft mattress.
b. Teach client to use lukewarm water when bathing.
c. Suggest that the client take a nap in the afternoon.
d. Suggest exercise with light weights several times daily.
Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid
arthritis. Clients are taught to avoid stressing joints, to use warm baths to relieve stiffness,
and to use a firm mattress.
7. The home health nurse is visiting a client who has rheumatoid arthritis (RA) and tells the
nurse about having chronically dry eyes. Which of the following actions by the nurse is
a. Reassure the client that dry eyes are a common problem with RA.
b. Teach the client more about adverse effects of the RA medications.
c. Suggest that the client start using over-the-counter (OTC) artificial tears.
d. Ask the health care provider about lowering the methotrexate dose.
The client's dry eyes are consistent with Sjögren syndrome, a common extra-articular
manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry
eyes are not an adverse effect of methotrexate. Although dry eyes are common in RA, it is
more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The
dry eyes are not caused by RA treatment, but by the disease itself.
8. Which of the following information should the nurse include when teaching
range-of-motion exercises to a client with an exacerbation of rheumatoid arthritis?
a. Affected joints should not be exercised when pain is present.
b. Application of cold packs before exercise may decrease joint pain.
c. Exercises should be performed passively by someone other than the client.
d. Walking may substitute for range-of-motion (ROM) exercises on some days.
Cold application is helpful in reducing pain during periods of exacerbation of RA. Because
the joint pain is chronic, clients are instructed to exercise even when joints are painful.
ROM exercises are intended to strengthen joints as well as improve flexibility, so passive
ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement
for ROM exercises.
9. The nurse is caring for a client with an acute exacerbation of rheumatoid arthritis and is
prescribed prednisone. Which of the following laboratory results should the nurse monitor
to determine whether the medication has been effective?
a. Blood glucose test
b. Liver function tests
c. C-reactive protein level
d. Serum electrolyte levels
C-reactive protein is a marker for inflammation, and a decrease would indicate that the
corticosteroid therapy was effective. Blood glucose and serum electrolyte levels also will
be monitored to check for adverse effects of prednisone. Liver function is not routinely
monitored for clients receiving steroids.
10. The nurse is teaching a client who has rheumatoid arthritis (RA) about how to manage
activities of daily living. Which of the following information should the nurse include in
the teaching plan?
a. Stand rather than sit when performing household chores.
b. Avoid activities that require continuous use of the same muscles.
c. Strengthen small hand muscles by wringing sponges or washcloths.
d. Protect the knee joints by sleeping with a small pillow under the knees.
Clients are advised to avoid repetitious movements. Sitting during household chores is
recommended to decrease stress on joints. Wringing water out of sponges would increase
the joint stress. Clients are encouraged to position joints in the extended position, and
sleeping with a pillow behind the knees would decrease the ability of the knee to extend
and also decrease knee range of motion (ROM).
11. The nurse is assisting a client with rheumatoid arthritis (RA) to plan a daily routine.
Which of the following information should the nurse include when discussing the most
helpful way to start the day?
a. A warm bath followed by a short rest
b. A short routine of isometric exercises
c. Active range-of-motion (ROM) exercises
d. Stretching exercises to relieve joint stiffness
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
12. The nurse is caring for a client who has rheumatoid arthritis (RA) and is prescribed
anakinra. Which of the following information should the nurse include when teaching the
client about this drug?
a. Self-administration of subcutaneous injections
b. Take the medication with at least 240 mL of fluid.
c. Avoid concurrently taking Aspirin or nonsteroidal anti-inflammatory drugs
d. Symptoms of gastrointestinal (GI) irritation or bleeding
Anakinra is administered by subcutaneous injection. GI bleeding is not an adverse effect
of this medication. Because the medication is injected, instructions to take it with 240 mL
of fluid would not be appropriate. The client is likely to be concurrently taking Aspirin or
NSAIDs, and these should not be discontinued.
13. The nurse is caring for a client who has three school-age children and recently diagnosed
with rheumatoid arthritis (RA). The client tells the nurse that the inability to be involved
in many family activities is causing stress at home. Which of the following responses by
the nurse is most appropriate?
a. "You may need to see a family therapist for some help."
b. "Tell me more about the situations that are causing stress."
c. "Perhaps it would be helpful for you and your family to get involved in a support
d. "Your family may need some help to understand the impact of your rheumatoid
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.
14. Which of the following information should the nurse include when teaching a client with
newly diagnosed ankylosing spondylitis (AS) about the management of the condition?
a. Exercise by taking long walks.
b. Do daily deep-breathing exercises.
c. Sleep on the side with hips flexed.
d. Take frequent naps during the day.
Deep-breathing exercises are used to decrease the risk for pulmonary complications that
may occur with the reduced chest expansion that can occur with ankylosing spondylitis
(AS). Clients should sleep on the back and avoid flexed positions. Prolonged standing and
walking should be avoided. There is no need for frequent naps.
15. The nurse is caring for a young adult client hospitalized with a fever and red, hot, painful
knees and is suspected of having septic arthritis. Which of the following information
obtained during the nursing history indicates a risk factor for septic arthritis?
a. Has a parent who has reactive arthritis.
b. Is sexually active and has multiple partners.
c. Recently returned from a trip to South America.
d. Had several sports-related knee injuries as a teenager.
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.
16. While working at a summer camp, the nurse notices a circular lesion with a red border and
clear centre on the arm of a client who is in the camp clinic complaining of chills and
muscle aches. Which of the following actions should the nurse take next?
a. Palpate the abdomen.
b. Auscultate the heart sounds.
c. Ask the client about recent outdoor activities.
d. Question the client about immunization history.
The client's clinical manifestations suggest possible Lyme disease. A history of recent
outdoor activities such as hikes will help confirm the diagnosis. The client's symptoms do
not suggest cardiac or abdominal problems or lack of immunization.
17. The nurse is caring for a young adult client with urethritis and knee pain who has been
diagnosed with reactive arthritis. Which of the following medications should the nurse
include in the teaching plan?
Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia
trachomatis and treatment with doxycycline. The other medications are used for chronic
inflammatory problems such as rheumatoid arthritis.
18. The nurse is caring for a client with an acute attack of gout and is being treated with
colchicine. Which of the following assessment data indicates the effectiveness of this
a. Relief of joint pain
b. Increased urine output
c. Elevated serum uric acid
d. Decreased white blood cells
Colchicine produces pain relief in 24-48 hours by decreasing inflammation. The
recommended increase in fluid intake of 2-3 L/day would increase urine output but would
not indicate the effectiveness of colchicine. Elevated uric acid levels would result in
increased symptoms. The WBC count might decrease with decreased inflammation, but
this would not be as useful in determining the effectiveness of colchicine as a decrease in
19. The nurse is caring for a client with gout and takes losartan for control of the condition.
Which of the following laboratory results should the nurse plan to monitor in the client?
a. Blood glucose
b. Blood pressure
c. Erythrocyte count
d. Lymphocyte count
Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not
affect blood glucose, red blood cell count (RBC), or lymphocytes.
20. The nurse is caring for a client in a long-term care facility who takes multiple medications
and has developed acute gouty arthritis. Which of the following medications should not be
given until the health care provider has been consulted?
Diuretic use increases uric acid levels and can precipitate gout attacks. The other
medications are safe to administer.
21. Which of the following statements by a young adult female client with systemic lupus
erythematosus (SLE) indicates that the client has understood the nurse's teaching about
management of the condition?
a. "I will use a sunscreen whenever I am outside."
b. "I will try to keep exercising even if I am tired."
c. "I should take birth control pills to keep from getting pregnant."
d. "I should not take Aspirin or nonsteroidal anti-inflammatory drugs."
Severe skin reactions can occur in clients with SLE who are exposed to the sun. Clients
should avoid fatigue by balancing exercise with rest periods as needed. Oral
contraceptives can exacerbate lupus. Aspirin and nonsteroidal anti-inflammatory drugs are
used to treat the musculo-skeletal manifestations of SLE.
22. The nurse is caring for a client with systemic lupus erythematosus (SLE) who has a facial
rash and alopecia who tells the nurse, "I hate the way I look! I never go anywhere except
here to the health clinic." Which of the following is an appropriate nursing diagnosis for
a. Activity intolerance related to immobility
b. Impaired social interaction related to insufficient knowledge about how to enhance
c. Impaired skin integrity related to excretions
d. Social isolation related to difficulty establishing relationships (embarrassment
about the effects of SLE)
The client's statement about not going anywhere because they hate they way they look
supports the diagnosis of social isolation because of embarrassment about the effects of
the SLE. Activity intolerance is a possible problem for clients with SLE, but the
information about this client does not support this as a diagnosis. The rash with SLE is
nonpruritic. There is no evidence of lack of social skills for this client.
23. To determine whether a client with joint swelling and pain has systemic lupus
erythematosus, which test will be most useful for the nurse to review?
a. Rheumatoid factor (RF)
b. Antinuclear antibody (ANA)
c. Anti-Smith antibody (Anti-Sm)
d. Lupus erythematosus (LE) cell prep
The anti-Sm is an antibody found almost exclusively in SLE. The other blood tests also are
used in screening but are not as specific to SLE.
24. The nurse is caring for a client with gout and has a red, painful left great toe. Which of the
following nursing actions should be included in the plan of care?
a. Gently palpate the toe to assess swelling.
b. Use pillows to keep the left foot elevated.
c. Use a footboard to hold bedding away from the toe.
d. Teach client to avoid use of acetaminophen.
Since any touch on the area of inflammation may increase pain, bedding should be held
away from the toe and touching the toe will be avoided. Elevation of the foot will not
reduce the pain, which is caused by the urate crystals. Acetaminophen can be used for pain
25. The health care provider has prescribed the following collaborative interventions for a
client who is taking azathioprine for systemic lupus erythematosus. Which of the
following orders should the nurse question?
a. Draw anti-DNA blood titre.
b. Administer varicella vaccine.
c. Use naproxen 200 mg BID.
d. Take famotidine 20 mg daily.
Live virus vaccines, such as varicella, are contraindicated in a client taking
immuno-suppressive drugs. The other orders are appropriate for the client.
26. The nurse is caring for a client who has systemic sclerosis manifested by CREST
(calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia)
syndrome. Which of the following actions should the nurse include in the plan of care?
a. Avoid use of capsaicin cream on hands.
b. Keep client's room warm and draft free.
c. Obtain capillary blood glucose before meals.
d. Assist to bathroom every 2 hours while awake.
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 levels or to assist the client to the
bathroom every 2 hours.
27. The nurse is teaching a client diagnosed with progressive systemic sclerosis about health
maintenance activities. Which of the following client statements indicates the need for
a. "I should lie down for an hour after meals."
b. "Paraffin baths can be used to help my hands."
c. "Lotions will help if I rub them in for a long time."
d. "I should perform range-of-motion exercises daily."
Because of the esophageal scarring, clients should sit up for 2 hours after eating. The other
client statements are correct and indicate that the teaching has been effective.
28. The nurse is caring for a client with rheumatoid arthritis who refuses to take the prescribed
methotrexate, telling the nurse "That drug has too many adverse effects. My arthritis isn't
that bad yet." Which of the following responses is most appropriate?
a. "You have the right to refuse to take the methotrexate."
b. "Methotrexate is less expensive than some of the newer drugs."
c. "It is important to start methotrexate early to decrease the extent of joint damage."
d. "Methotrexate is effective and has fewer adverse effects than some of the other drugs."
Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the
joint degeneration that occurs as soon as the first year with RA. The other statements are
accurate, but the most important point for the client to understand is that it is important to
start DMARDs as quickly as possible.
29. The nurse is caring for a client with an exacerbation of rheumatoid arthritis (RA) and is
taking prednisone 40 mg daily. Which of these assessment data obtained by the nurse
indicate that the client is experiencing an adverse effect of the medication?
a. The client's blood glucose is 9.2 mmol/L.
b. The client has no improvement in symptoms.
c. The client has experienced a recent 2.5 kg weight loss.
d. The client's erythrocyte sedimentation rate (ESR) has increased.
Corticosteroids have the potential to cause diabetes mellitus. The finding of an elevated
blood glucose reflects this adverse effect of prednisone. Corticosteroids increase appetite
and lead to weight gain. An elevated ESR and no improvement in symptoms would
indicate that the prednisone was not effective but would not be adverse effects of the
30. The home health nurse is doing a follow-up visit to a client with recently diagnosed
rheumatoid arthritis (RA). Which of the following assessments made by the nurse
indicates that more client teaching is needed?
a. The client requires a 2-hour midday nap.
b. The client has been taking 16 Aspirins daily.
c. The client sits on a stool when preparing meals.
d. The client sleeps with two pillows under the head.
The joints should be maintained in an extended position to avoid contractures, so clients
should use a small, flat pillow for sleeping. The other information is appropriate for a
client with RA and indicates that teaching has been effective.
31. The nurse is caring for a client with an acute attack of gout in the left great toe and has a
new prescription for probenecid. Which of the following information about the client's
home routine indicates a need for teaching regarding gout management?
a. The client sleeps about 8-10 hours every night.
b. The client usually eats beef once or twice a week.
c. The client generally drinks about 3 L of juice and water daily.
d. The client takes one Aspirin a day prophylactically to prevent angina.
Aspirin interferes with the effectiveness of probenecid and should not be taken when the
client is taking probenecid. The client's sleep pattern will not affect gout management.
Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for
the client with gout.
32. The nurse is reviewing laboratory results for a client with systemic lupus erythematosus
(SLE). Which of the following results is most important to communicate to the health care
a. Decreased C-reactive protein (CRP)
b. Mild proteinuria
c. Positive antinuclear antibodies (ANA)
d. Positive lupus erythematosus cell prep
The mild proteinuria indicates possible lupus nephritis and a need for a change in therapy
to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA
would be expected in a client with SLE. A drop in CRP shows an improvement in the
33. The nurse is assessing a client who is taking hydroxychloroquine to treat rheumatoid
arthritis. Which of the following findings is most important to report to the health care
a. Abdominal cramping
b. Complaint of blurry vision
c. Phalangeal joint tenderness
d. Blood pressure 170/84 mm Hg
Plaquenil can cause retinopathy; the medication should be stopped. The other findings are
not related to the medication, although they also will be reported.
34. The nurse has completed the health history with a female client who is taking methotrexate
to treat rheumatoid arthritis. Which of the following information about the client is most
important for the nurse to report to the health care provider?
a. The client had a history of infectious mononucleosis as a teenager.
b. The client is trying to have a baby before her disease becomes more severe.
c. The client has a family history of age-related macular degeneration of the retina.
d. The client has been using large doses of vitamins and health foods to treat the RA.
Methotrexate is teratogenic, and the client should be taking contraceptives during
methotrexate therapy and up to 3 months after therapy. The other information will not
impact the choice of methotrexate as therapy.
35. The nurse is reviewing laboratory data for a client who is taking methotrexate to treat
rheumatoid arthritis. Which of the following information is most important to
communicate to the health care provider?
a. The blood glucose is 4.2 mmol/L.
b. The rheumatoid factor is positive.
c. The white blood cell (WBC) count is 1.5 ´ 109/L.
d. The erythrocyte sedimentation rate is elevated.
Bone marrow suppression is a possible adverse effect of methotrexate, and the client's low
WBC count places the client at high risk for infection. The elevated erythrocyte
sedimentation rate and positive rheumatoid factor are expected in rheumatoid arthritis. The
blood glucose is normal.
36. Which of the following actions should the nurse implement for a client with septic
a. Hot compress on affected area tid
b. Active ROM exercises qid
c. Monitor BP q4h
d. Passive ROM exercises bid
Local hot compresses can also help relieve pain associated with septic arthritis. Only
gentle ROM exercises are advocated. The temperature should be monitored often but the
BP does not need to be assessed q4h.
37. The nurse is caring for a client with polymyositis and has joint pain, an erythematosus
facial rash with eyelid edema, and a weak, hoarse voice. Which of the following nursing
diagnoses is priority?
a. Acute pain related to biological injury agent (inflammation)
b. Risk for aspiration as evidenced by barrier to elevating upper body
c. Risk for impaired skin integrity as evidenced by excretions
d. Risk for dry eye as evidenced by insufficient knowledge of modifiable factors
The client's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles
and a high risk for aspiration. The other nursing diagnoses also are appropriate but are not
as high a priority as the maintenance of the client's airway.
38. The nurse is caring for a client with dermatomyositis who is receiving long-term
prednisone therapy. Which of the following findings is most important to report to the
health care provider?
a. The blood glucose is 6.2 mmol/L.
b. The client has painful hematuria.
c. The client has an increased appetite.
d. Acne is noted on the back and face.
Corticosteroid use is associated with increased risk for infection, so the nurse should report
the urinary tract symptoms immediately to the health care provider. The increase in blood
glucose, increased appetite, and acne also are adverse effects of corticosteroid use, but do
not need diagnosis and treatment as rapidly as the probable urinary tract infection.
39. Which of the following clients seen by the nurse in the outpatient clinic is most likely to
require teaching about ways to reduce risk for osteoarthritis (OA)?
a. A 56-year-old man who is a member of a construction crew
b. A 24-year-old man who participates in a summer softball team
c. A 49-year-old woman who works on an automotive assembly line
d. A 36-year-old woman who is newly diagnosed with diabetes mellitus
OA is more likely to occur in women as a result of estrogen reduction at menopause and in
individuals whose work involves repetitive movements and lifting. Moderate exercise,
such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a
construction crew would involve nonrepetitive work and thus would not be as risky.
40. The nurse is conducting client teaching with a client who has systemic lupus
erythematosus and is prescribed hydroxychloroquine. Which of the following information
should the nurse include in the teaching plan?
a. Has a rapid therapeutic response
b. Vision assessment every 6-12 months
c. Does not prevent flare-ups of symptoms
d. Can only be administered intravenously
Funduscopic and visual field examinations must be performed by an ophthalmologist
every 6-12 months when patients are on hydroxychloroquine. Hydroxychloroquine is
often used to treat fatigue and moderate skin and joint problems. Unlike the rapid response
noted with corticosteroids, effects of antimalarial therapy may not be noticed for several
months. Flares may also be prevented with these drugs.
1. The nurse is assessing a client with fibromyalgia. Which of the following symptoms
should the nurse expect the client to report? (Select all that apply.)
a. Sleep disturbances
b. Multiple tender points
c. Cardiac palpitations and dizziness
d. Multijoint pain with inflammation and swelling
e. Widespread bilateral, burning musculo-skeletal pain
ANS: A, B, E
These symptoms are commonly described by clients with fibromyalgia. Cardiac
involvement and joint inflammation are not typical of FMS.
2. The nurse is conducting discharge teaching with a client who has systemic lupus
erythematosus. Which of the following information should the nurse discuss with this
client? (Select all that apply.)
a. Use of heat for arthralgia
b. Avoidance of physical stress
c. Use an unscented powder after bathing
d. Refrain from daily exercise
e. Use sunscreen when exposed to sun
ANS: A, B, E
Teaching about SLE includes the use of heat for arthralgia, avoidance of physical stress
and using sunscreen when exposed to the sun. Therapeutic exercise is recommended. The
use of drying soaps, powders, and household chemicals should be avoided.
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