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Chapter: Chapter 54: Assessment and Management of Patients With Rheumatic Disorders

Multiple Choice

1. A 44-year-old patient has been seen in the clinic for suspected arthritis. She is to undergo a procedure to retrieve synovial fluid from her knee for a definitive diagnosis. The nurse knows that which of the following procedures will be involved? A) Angiography B) Myelography C) Paracentesis D) Arthocentesis Ans: D Chapter: 54 Client Needs: A-1 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 2 Page and Header: 1643, Diffuse Connective Tissue Diseases Feedback: Arthrocentesis (needle aspiration of synovial fluid) may be performed not only to obtain a sample of synovial fluid for analysis, but also to relieve pain caused by pressure of increased fluid volume, usually in the knee or shoulder. Angiography is an x-ray study of

circulation with a contrast agent injected into a selected artery. Myelography is an x-tray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Paracentesis is removal of fluid (ascites) from the peritoneal cavity through a small surgical incision or puncture made through the abdominal all under sterile conditions.

2. A patient in the early stage of rheumatoid arthritis has been admitted to your unit. What medication classification would the nurse expect to be ordered for this patient? A) Antimalarial agents B) NSAIDs C) Xanthine oxidase inhibitors D) Uricosuric agents Ans: B Chapter: 54 Client Needs: D-2 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 3 Page and Header: 1643, Diffuse Connective Tissue Diseases Feedback: Medical management of RA begins with therapeutic doses of salicylates or NSAIDs. Antimalarial agents are used in the treatment of systemic lupus erythematosus. Xanthine oxidase inhibitors and uricosuric agents are used in the treatment of gout.

3. You are doing the initial assessment of a patient admitted to your unit with systemic lupus erythematosus. What skin manifestation would the nurse expect to find on this patient? A) Petechiae B) Butterfly rash across bridge of nose and cheeks C) Absence of wrinkles D) Weight gain Ans: B Chapter: 54 Client Needs: A-1 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 4

Page and Header: 1647, Diffuse Connective Tissue Diseases Feedback: An acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks occurs in systemic lupus erythematosus (SLE). Petechiae are pinpoint skin hemorrhages, which are not a clinical manifestation of SLE. Wrinkles and lines are obliterated in scleroderma. Weight loss is a classic symptom of SLE.

4. A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse would include which of the following as a causative agent in gout? A) Thrombocytopenia B) Hypouricemia C) Hyperuricemia D) Hypocalcemia Ans: C Chapter: 54 Client Needs: A-1 Cognitive Level: Application Difficulty: Moderate Integrated Process: Teaching/Learning Objective: 1 Page and Header: 1653, Metabolic and Endocrine Diseases Associated with Rheumatic Disorders Feedback: Oversecretion of uric acid, a renal defect resulting in decreased excretion of uric acid, or a combination of both occurs in gout. Hyperuricemia occurs. Thrombocytopenia is indicative of systemic lupus erythematosus. Hypercalcemia can cause kidney stones related to gout.

5. The nurse knows that as the symptoms of a disease change, modifications need to be made in the treatment plan. The nurse would teach the patient with rheumatic disease that it is acceptable to perform passive range of motion during which phase of the inflammatory process? A) Acute exacerbation, severe pain B) Subacute exacerbation, moderate pain C) Subacute exacerbation, minimal pain D) Remission Ans: A Chapter: 54 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate

Integrated Process: Teaching/Learning Objective: 6 Page and Header: 1637, Rheumatic Diseases Feedback: Active range of motion and isometric exercises are recommended for periods of inactive disease. Active assisted or active range of motion within pain tolerance is suggested for subacute inflammation. Passive range of motion is suggested during periods of acute exacerbation with severe pain.

6. The nursing instructor is talking with the pathophysiology class. What diffuse connective tissue disease would the instructor tell the class is the result of an autoimmune reaction that results in phagocytosis, producing enzymes within the joint that break down collagen and cause edema? A) Rheumatoid arthritis (RA) B) Systemic lupus erythematosus C) Osteoporosis D) Polymyositis Ans: A Chapter: 54 Client Needs: D-4 Cognitive Level: Comprehension Difficulty: Moderate Integrated Process: Nursing Process Objective: 5 Page and Header: 1643, Diffuse Connective Tissue Diseases Feedback: In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately form pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not result in phagocytosis.

7. A patient has been has been admitted to your unit with a diagnoses of rheumatoid arthritis. The nurse documents joint pain and swelling in her initial assessment. In addition to these findings, what is a classic sign of rheumatoid arthritis? A) Cool extremities B) Butterfly rash on face C) Joint stiffness D) Absence of wrinkles Ans: C

Chapter: 54 Client Needs: A-1 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 2 Page and Header: 1643, Diffuse Connective Tissue Diseases Feedback: In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning. In rheumatoid arthritis, physical signs include warm, swollen, painful joints. A butterfly-shaped rash across the bridge of the nose and cheeks is a skin manifestation of systemic lupus erythematosus. In scleroderma, wrinkles and lines are obliterated.

8. A patient has had rheumatoid arthritis for over 10 years. The physician has now ordered cyclophosphamide (Cytoxan) for treatment of the disease. The nurse must be alert to what side effects of this medication when administering an immunosuppressant? A) Infection B) Nystagmus C) Muscle rigidity D) Hyperthermia Ans: A Chapter: 54 Client Needs: D-2 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 3 Page and Header: 1645, Diffuse Connective Tissue Diseases Feedback: When administering immunosuppressant agents, such as Cytoxan, the nurse should be alert to manifestations of bone marrow suppression. Clinical manifestations of infection would be an important assessment for this patient. Nystagmus is a clinical manifestation of multiple sclerosis. Muscle rigidity occurs in Parkinson's disease. Hyperthermia does not occur as a common manifestation when receiving immunosuppressant agents.

9. The clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient? A) Impaired skin integrity B) Altered Nutrition

C) Disturbed sleep pattern D) Fatigue Ans: D Chapter: 54 Client Needs: C Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 4 Page and Header: 1654, Fibromyalgia Feedback: Fatigue would be the priority nursing diagnosis in this scenario. Fibromyalgia is a common syndrome that involves fatigue, generalized muscle aching, and stiffness. Impaired skin integrity would generally not be a diagnosis seen in these patients. Altered nutrition and disturbed sleep pattern are potential nursing diagnoses, but are not the priority.

10. A nurse is caring for a patient newly diagnosed with osteoarthritis (OA). The patient asks the nurse what causes OA. What would the nurse tell the patient is a well-recognized risk factor for osteoarthritis? A) Smoking B) Obesity C) Weight loss D) Less than 20 years of age Ans: B Chapter: 54 Client Needs: A-1 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 1 Page and Header: 1651, Degenerative Joint Disease (Osteoarthritis) Feedback: Risk factors for osteoarthritis include increased age, obesity, and previous joint damage. Risk factors of OA do not include smoking, weight loss, or being less than 20 years of age.

11. You are caring for a 69-year-old patient who has just been admitted to your unit. The patient asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA).

What is the best response by the nurse? A) OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints. B) OA and RA are very similar. OA affects the smaller joints, and RA affects the larger, weightbearing joints. C) OA affects joints on both sides of the body. RA is usually unilateral. D) OA is more common in women. RA is more common in men. Ans: A Chapter: 54 Client Needs: D-4 Cognitive Level: Application Difficulty: Difficult Integrated Process: Teaching/Learning Objective: 3 Page and Header: 1650, Degenerative Joint Disease (Osteoarthritis) Feedback: OA is a degenerative arthritis, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. OA may occur in one hip or knee and not the other, whereas RA commonly affects the same joints bilaterally. RA is more common in women, while OA affects both sexes equally.

12. A patient with systemic lupus erythematosus (SLE) is getting ready for discharge. The nurse knows the patient has understood the patient teaching when the patient states she needs to what? A) Get as much exposure to sunlight as possible to help control skin rashes. B) Be as active as possible between flare-ups. C) Monitor body temperature. D) Stop her corticosteroids when symptoms are relieved. Ans: C Chapter: 54 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Process: Teaching/Learning Objective: 4 Page and Header: 1648, Diffuse Connective Tissue Diseases Feedback: Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Patients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the

adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially lifethreatening situation.

13. A patient with an exacerbation of his chronic systemic lupus erythematosus (SLE) has been hospitalized on your unit. He gets angry when his call bell isn't answered immediately. What would be the most appropriate response? A) "You seem angry. Would you like to talk about it?" B) "Calm down. You know that stress will make your symptoms worse." C) "Would you like to talk about the problem with the nursing supervisor?" D) "I can see you're angry. I'll come back when you've calmed down." Ans: A Chapter: 54 Client Needs: C Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 3 Page and Header: 1648, Diffuse Connective Tissue Diseases Feedback: The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care and sensitivity to the psychological reactions of the patient. Offering to listen to the patient express anger can help the nurse and the patient understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the patient to calm down doesn't acknowledge his feelings. Ignoring the patient's feelings suggests that the nurse has no interest in what the patient has said. Offering to get the nursing supervisor also doesn't acknowledge the patient's feelings.

14. A nurse is caring for a 78-year-old patient with a history of osteoarthritis. When doing the initial assessment the nurse knows that he will most probably find what signs and symptoms? A) Joint pain, crepitus, Heberden's nodes B) Hot, inflamed joints; crepitus; joint pain C) Tophi, enlarged joints, Bouchard's nodes D) Swelling, joint pain, tenderness on palpation Ans: A Chapter: 54 Client Needs: D-4 Cognitive Level: Application Difficulty: Difficult

Integrated Process: Nursing Process Objective: 4 Page and Header: 1651, Degenerative Joint Disease (Osteoarthritis) Feedback: The primary clinical manifestations of OA are pain, stiffness, and functional impairment. The pain is caused by an inflamed synovium, stretching of the joint capsule or ligaments, irritation of nerve endings in the periosteum over osteophytes (bone spurs), trabecular microfracture, intraosseous hypertension, bursitis, tendinitis, and muscle spasm. Stiffness, which is most commonly experienced in the morning or after awakening, usually lasts less than 30 minutes and decreases with movement. Functional impairment results from pain on movement and limited motion caused by structural changes in the joints. The joint pain occurs with movement and is relieved by rest. As the disease progresses, pain may also occur at rest. Heberden's nodes are bony growths that occur at the distal interphalangeal joints. Bouchard's nodes involve the proximal interphalangeal joints. Tophi are deposits of sodium urate crystals that occur in chronic gout, not osteoarthritis. Hot, inflamed joints rarely occur in osteoarthritis. Swelling, joint pain, and tenderness on palpation occur with a sprain injury.

15. A patient who has been newly diagnosed with systemic lupus erythematosus has been admitted to your unit. You know that a typical diagnostic finding related to this disease is what? A) Thrombocytopenia B) Elevated hemoglobin level C) Negative antinuclear antibodies level D) Proteinuria Ans: A Chapter: 54 Client Needs: A-1 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 2 Page and Header: 1647, Diffuse Connective Tissue Diseases Feedback: Blood testing reveals moderate to severe anemia, thrombocytopenia, leukocytosis, and positive antinuclear antibodies. Proteinuria is not diagnostic of systemic lupus erythematosus.

16. In talking with the nursing students about scleroderma the nursing instructor refers to the CREST syndrome. These are clinical manifestations that may be related to scleroderma. What does the R in CREST stand for? A) Raynaud's phenomenon

B) Reye's syndrome C) Rhintis D) Renal failure Ans: A Chapter: 54 Client Needs: A-1 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 2 Page and Header: 1648, Diffuse Connective Tissue Diseases Feedback: The R in CREST stands for Raynaud's phenomenon.

17. Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for this patient would know that what laboratory finding would indicate bone marrow suppression in this patient? A) Hyperuricemia B) Increased erythrocyte sedimentation rate C) Elevated serum creatinine D) Decreased platelets Ans: D Chapter: 54 Client Needs: A-1 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 3 Page and Header: 1654, Metabolic and Endocrine Diseases Associated with Rheumatic Disorders Feedback: Thrombocytopenia occurs in bone marrow suppression. Hyperuricemia occurs in gout, but is not caused by bone marrow suppression. Increased sedimentation rate may occur from inflammation associated with gout, but is not related to bone marrow suppression. An elevated serum creatinine level may indicate renal damage associated with systemic lupus erythematosus.

18. A patient with rheumatic disease is complaining of stomatitis. The nurse caring for the patient should further assess the patient for the side effects of what medications? A) Corticosteroids

B) Gold-containing compounds C) Antimalarials D) Salicylate therapy Ans: B Chapter: 54 Client Needs: D-2 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 4 Page and Header: 1638, Rheumatic Diseases Feedback: The DMARD category of antimalarials may cause visual changes, gastrointestinal (GI) upset, skin rash, headaches, photosensitivity, and bleaching of hair. Tinnitis is associated with salicylate therapy, stomatitis is associated with gold therapy, and hirsutism is associated with corticosteroid therapy.

19. The nurse is planning patient education for a patient being discharged home with a diagnosis of rheumatic disease. The patient has been prescribed antimalarials for treatment, so the nurse knows to teach the patient to monitor herself for what? A) Tinnitus B) Visual changes C) Stomatitis D) Hirsutism Ans: B Chapter: 54 Client Needs: D-2 Cognitive Level: Application Difficulty: Moderate Integrated Process: Teaching/Learning Objective: 4 Page and Header: 1638, Rheumatic Diseases Feedback: The DMARD category of antimalarials may cause visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. Tinnitis is associated with salicylate therapy, stomatitis is associated with gold therapy, and hirsutism is associated with corticosteroid therapy.

20. The nurse is developing a teaching plan for a patient with rheumatic disease who is being

prescribed salicylate therapy to monitor herself for what? A) Tinnitus B) Visual changes C) Stomatitis D) Hirsutism Ans: A Chapter: 54 Client Needs: D-2 Cognitive Level: Application Difficulty: Moderate Integrated Process: Teaching/Learning Objective: 4 Page and Header: 1638, Rheumatic Diseases Feedback: The DMARD category of antimalarials may cause visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. Tinnitis is associated with salicylate therapy, stomatitis is associated with gold therapy, and hirsutism is associated with corticosteroid therapy.

Multiple Selection

21. In your pathophysiology class you are studying the rheumatic disorders. What should you learn about polymyalgia rheumatica and its pathophysiology? (Mark all that apply.) A) There is an association with the genetic marker HLA-DR4 B) Immunoglobulin deposits suggest an autoimmune process C) Occurs predominately in Asians D) There is no genetic association known E) Occurs predominately in Caucasians Ans: A, B, E Chapter: 54 Client Needs: B Cognitive Level: Knowledge Difficulty: Moderate Integrated Process: Teaching/Learning Objective: 1 Page and Header: 1650, Diffuse Connective Tissue Diseases Feedback: The underlying mechanism involved with polymyalgia rheumatica is unknown. This disease occurs predominately in Caucasians and often in first-degree relatives. An association with the genetic marker HLA-DR4 suggests a familial predisposition. Immunoglobulin deposits in the

walls of inflamed temporal arteries also suggest an autoimmune process. This makes options C and D incorrect.

Multiple Choice

22. A patient with osteoarthritis comes to the clinic because he is not able to control the pain. The patient asks the nurse why it hurts so bad. What would be the nurse's best response? A) Don't worry about why it hurts, let's just concentrate on taking away the pain. B) You are hurting because you aren't following your treatment regimen. C) The pain you are feeling is psychological. What is going on in your life to make you hurt so bad? D) You are experiencing pain from irritated nerve endings and muscle spasms. Ans: D Chapter: 54 Client Needs: D-4 Cognitive Level: Application Difficulty: Moderate Integrated Process: Communication and Documentation Objective: 1 Page and Header: 1651, Degenerative Joint Disease (Osteoarthritis) Feedback: The pain is caused by an inflamed synovium, stretching of the joint capsule or ligaments, irritation of nerve endings in the periosteum over osteophytes (bone spurs), trabecular microfracture, intraosseous hypertension, bursitis, tendinitis, and muscle spasm. Option A is incorrect because it does not answer the patient's question. Nowhere in the scenario does it say the patient is not following their treatment regimen. Option C is incorrect because no information you are given indicates psychological problems with the patient.

23. What causes the inflammatory response in a patient diagnosed with gout? A) Phosphate crystals B) Calcium crystals C) Urate crystals D) Sodium crystals Ans: C Chapter: 54

Client Needs: B Cognitive Level: Knowledge Difficulty: Easy Integrated Process: Nursing Process Objective: 1 Page and Header: 1653, Metabolic and Endocrine Diseases Associated with Rheumatic Disorders Feedback: Attacks of gout appear to be related to sudden increases or decreases of serum uric acid levels. When the urate crystals precipitate within a joint, an inflammatory response occurs, and an attack of gout begins. This makes options A, B, and D incorrect.

24. The pathophysiology instructor is discussing the disease process of rheumatic disorders. What would the instructor tell you is the cause of degeneration in the rheumatic disorders? A) Too much activity B) Lack of fluid in the joints C) Calcemia D) Pannus Ans: D Chapter: 54 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Process: Nursing Process Objective: 1 Page and Header: 1632, Rheumatic Diseases Feedback: Degeneration occurs as a secondary process, resulting from the effect of pannus (proliferation of newly formed synovial tissue infiltrated with inflammatory cells). Degeneration is not caused by to much activity or lack of fluid in the joints. Calcemia is a detractor for this question.

25. A patient is suspected of having a rheumatic disorder. What is one laboratory test the nurse would expect the physician to order? A) Erythrocyte count B) Erythrocyte sedimentation rate C) Creatinine clearance D) Basic metabolic panel Ans: B

Chapter: 54 Client Needs: D-4 Cognitive Level: Application Difficulty: Difficult Integrated Process: Nursing Process Objective: 2 Page and Header: 1633, Rheumatic Diseases Feedback: The erythrocyte sedimentation rate (ESR) reflects inflammatory activity and, indirectly, the progression or remission of disease.

26. A patient with SLE has come to the clinic for a routine check-up. Each time the patient is routinely examined several systems are assessed. When the nurse assesses the patient's cardiovascular system what is one thing that is being assessed for? A) Heart failure B) Mitral valve failure C) Pericardial friction rub D) Pericardial effusion Ans: C Chapter: 54 Client Needs: D-4 Cognitive Level: Analysis Difficulty: Moderate Integrated Process: Nursing Process Objective: 2 Page and Header: 1647, Diffuse Connective Tissue Diseases Feedback: Cardiovascular assessment includes auscultation for pericardial friction rub, possibly associated with myocarditis and accompanying pleural effusions. Therefore options A, B, and D are incorrect.

27. You are studying the rheumatic disorders. You should know that one rheumatic disorder has as its diagnostic test a skin biopsy. Which disorder is it? A) Polymyositis B) Polymyalgia rheumatica C) Psoriatic arthritis D) Scleroderma Ans: D

Chapter: 54 Client Needs: B Cognitive Level: Comprehension Difficulty: Difficult Integrated Process: Nursing Process Objective: 2 Page and Header: 1649, Diffuse Connective Tissue Diseases Feedback: A skin biopsy is performed to identify cellular changes specific to scleroderma. Skin biopsies are not diagnostic of polymyositis, polymyalgia rheumatica, or psoriatic arthritis.

28. A 21-year-old male has just been diagnosed with a spondyloarthropathy. What will be a major nursing intervention for this patient? A) Referral for assistive devices B) Teaching about symptom management C) Referral to classes to stop smoking D) Setting up an exercise program Ans: B Chapter: 54 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Teaching/Learning Objective: 3 Page and Header: 1653, Spondyloarthropathies Feedback: Major nursing interventions in the spondyloarthropathies are related to symptom management and maintenance of optimal functioning. Therefore options A, C, and D are incorrect.

29. A patient with SLE asks the nurse why she has to come to the office so often for check-ups. What would be the nurse's best response? A) Taking care of you in the best way involves seeing you face-to-face. B) Taking care of you in the best way involves making sure you are taking your medication the way it is ordered. C) Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is controlling the disease. D) Taking care of you in the best way involves drawing blood work every month. Ans: C

Chapter: 54 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Process: Communication and Documentation Objective: 3 Page and Header: 1648, Diffuse Connective Tissue Diseases Feedback: The goals of treatment include preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease-related disabilities, and preventing complications from therapy. Management of SLE involves regular monitoring to assess disease activity and therapeutic effectiveness. Option A is incorrect as it does not answer the patient's question. Option B is incorrect because it is not a complete answer. Option D is incorrect because it is wrong.

30. The patient is diagnosed with polymyalgia rheumatica and is placed on steroids. A concern for this patient is that he will stop taking the medication as soon as he starts to feel better. Why must the nurse emphasize the need for continued adherence to the prescribed medication? A) To avoid complications of giant cell arteritis, such as deafness B) To avoid complications of small cell arteritis such as osteoporosis C) To avoid complications of small cell arteritis such as degenerative joint disease D) To avoid complications of giant cell arteritis, such as blindness Ans: D Chapter: 54 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Teaching/Learning Objective: 5 Page and Header: 1650, Diffuse Connective Tissue Diseases Feedback: The nurse must emphasize to the patient the need for continued adherence to the prescribed medication regimen to avoid complications of giant cell arteritis, such as blindness. Options A, B, and C are incorrect.

31. You are discussing a patient with polymyositis with a care team consisting of a physician, a social worker, OT and PT, and a home health nurse. The home health nurse reports that the patient's proximal muscle weakness has gotten more pronounced. The home health nurse asks for a referral to and OT and PT to assess for what?

A) B) C) D)

Exercises to strengthen the muscles Possible assistive devices to help with ADLs Family educational needs Social support network

Ans: B Chapter: 54 Client Needs: A-1 Cognitive Level: Comprehension Difficulty: Moderate Integrated Process: Nursing Process Objective: 5 Page and Header: 1649, Diffuse Connective Tissue Diseases Feedback: Patients with polymyositis may have symptoms similar to those of other inflammatory diseases. However, proximal muscle weakness is characteristic, making activities such as combing the hair, reaching overhead, and using stairs difficult. Therefore, use of assistive devices may be recommended, and referral to occupational or physical therapy may be warranted. The muscle weakness is a product of the disease process, not lack of exercise. A physical therapist and an occupational therapist would not assess family educational needs or the patient's social support network.

Multiple Selection

32. A 25-year-old mother of a 6-month-old has just been diagnosed with rheumatoid arthritis. The nurse is planning the teaching for this patient. What will the teaching focus on? (Mark all that apply.) A) Physical limitations and adaptations B) Nutrition and weight maintenance C) The disorder itself D) Possible changes related to the disorder E) Patient safety in the home Ans: C, D, E Chapter: 54 Client Needs: D-4 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Teaching/Learning Objective: 5

Page and Header: 1645, Diffuse Connective Tissue Diseases Feedback: Patient teaching focuses on the disorder itself, the possible changes related to the disorder, the therapeutic regimen prescribed to treat it, the potential side effects of medications, strategies to maintain independence and function, and patient safety in the home. The teaching for this patient will not focus on physical limitations and adaptations or nutrition and weight maintenance.

Multiple Choice

33. You are preparing a teaching plan for a patient newly diagnosed with rheumatoid arthritis. What is a priority subject the nurse needs to teach this patient? A) Diet B) Activity limitations C) Signs and symptoms of exacerbation D) The side effects of the medications Ans: D Chapter: 54 Client Needs: D-2 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Teaching/Learning Objective: 5 Page and Header: 1645, Diffuse Connective Tissue Diseases Feedback: The nurse, who can be available for consultation between physician visits, works to help the patient recognize and deal with side effects. Diet, activity limitations, and signs and symptoms of an exacerbation are not priorities in teaching a newly diagnosed patient.

34. A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of the right big toe. The patient is diagnosed with gout. When planning teaching for this patient, what would the nurse know is an important factor in the management of this disease? A) Maintain body weight at 10% below recommendation of weight for height B) Restrict consumption of foods high in purines C) Stop smoking D) Restrict weight bearing on right foot

Ans: B Chapter: 54 Client Needs: D-4 Cognitive Level: Application Difficulty: Moderate Integrated Process: Teaching/Learning Objective: 5 Page and Header: 1654, Metabolic and Endocrine Diseases Associated with Rheumatic Disorders Feedback: Although severe dietary restriction is not necessary, the nurse should encourage the patient to restrict consumption of foods high in purines, especially organ meats, and to limit alcohol intake. Maintenance of normal body weight should be encouraged. Restricting weight bearing and stopping smoking are incorrect answers.

35. The clinic nurse is caring for a patient diagnosed with rheumatoid arthritis. The patient tells you she has not been taking her medication because she cannot get the medicine bottle open. The patient says it is too hard to get the child-proof tops off the bottle. What suggestion could you make that would be the most helpful to your patient, aiding her in being more compliant with her medication treatment regimen? A) Have a neighbor come over and open the bottles for you. B) Have a family member come and open the bottles for you. C) Take your medicine bottles back to the pharmacy and have them put tops on them that are not childproof. D) Get a 7-day pill holder and have someone fill it for you each week. Ans: C Chapter: 54 Client Needs: D-2 Cognitive Level: Analysis Difficulty: Moderate Integrated Process: Caring Objective: 6 Page and Header: 1642, Rheumatic Diseases Feedback: Instruct in correct self-administration, potential side effects, and importance of monitoring. Outcome = Takes medication as prescribed and lists potential side effects. Options A, B, and D are incorrect because they are possibly lowering the patient's self-image and taking away some of her independence.

36. A patient with rheumatoid arthritis calls the nurse and reports having mild side effects from his

medication. The patient also tells the nurse his disease is worse and he is losing some of his ability to function. The nurse schedules an appointment for the patient to see the physician that afternoon. What order might the nurse expect to receive from the physician for this patient? A) Increase the dosage of the medication. B) Arrange for patient to be hospitalized. C) Refer to psychologist for help improving self-image. D) Decrease the dosage of the medication. Ans: D Chapter: 54 Client Needs: D-2 Cognitive Level: Application Difficulty: Easy Integrated Process: Nursing Process Objective: 6 Page and Header: 1645, Diffuse Connective Tissue Diseases Feedback: The nurse, who can be available for consultation between physician visits, works to help the patient recognize and deal with these side effects. The medication may need to be stopped or the dose reduced. There is nothing in the scenario that indicates the patient needs to be hospitalized or needs to see a psychologist.

37. The patient has just been told by his physician that he has scleroderma. The physician tells the patient that he is going to order some tests to assess for systemic involvement. The nurse knows that the systems to be assessed include what? A) Hepatic B) Gastrointestinal C) Musculoskeletal D) Neurologic Ans: B Chapter: 54 Client Needs: D-4 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 4 Page and Header: 1649, Diffuse Connective Tissue Diseases Feedback: Assessment of systemic involvement requires a systems review with special attention to gastrointestinal, pulmonary, renal, and cardiac systems. This makes options A, C, and D incorrect.

38. The nursing instructor is discussing the care of the patient with systemic lupus erythematosus. The instructor points out to the class of nursing students that a priority parameter for the teaching plan for a newly diagnosed patient is what? A) Teaching about refraining from sing lotions on the skin B) Teaching about the disease itself C) Teaching about nutrition D) Teaching about renal calculi Ans: B Chapter: 54 Client Needs: B Cognitive Level: Comprehension Difficulty: Moderate Integrated Process: Teaching/Learning Objective: 5 Page and Header: 1648, Diffuse Connective Tissue Diseases Feedback: The most common nursing diagnoses include fatigue, impaired skin integrity, body image disturbance, and lack of knowledge for self-management decisions. The nurse would not tell the patient not to use lotions on the skin; nutrition is not a priority for the newly diagnosed and neither are renal calculi.

39. A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes the patient has lost some of her ability to function since her last office visit. What might be an appropriate intervention for the nurse to make for this patient? A) Recommend to the physician that the patient be hospitalized. B) Ask the physician for a referral to an arthritis support group in the community. C) Make a referral for home health so the patient can be assessed in her own environment. D) Make referrals for occupational therapy and physical therapy. Ans: C Chapter: 54 Client Needs: D-4 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 6 Page and Header: 1646, Diffuse Connective Tissue Diseases Feedback: Appropriate adaptive equipment needed for increased independence is often identified

more readily when the nurse sees how the patient functions in the home. There is nothing in the scenario that indicates the patient needs to be hospitalized. The nurse could make the referral to the support group; the physician does not need to do this. The nurse could not make referrals for occupational therapy and physical therapy.

40. You are assessing a patient diagnosed with rheumatoid arthritis. The patient tells you that the first joint involved was the right knee. The patient goes on to say that he used to love to walk but just can't handle much of it anymore. What would be the nurse's best response? A) Sometimes you just have to push through the pain to do things you like to do. B) I will get you a referral for physical therapy. C) I am sure you can find other things you like to do just as well. D) Your inability to do things you used to do is telling you that your disease is getting worse. Ans: D Chapter: 54 Client Needs: B Cognitive Level: Comprehension Difficulty: Easy Integrated Process: Caring Objective: 6 Page and Header: 1633, Rheumatic Diseases Feedback: Decreased range of motion may indicate severity or progression of disease. Options A and C are incorrect as they are insensitive to the patient's feelings and needs. Option B is incorrect, as a nurse does not make a referral to physical therapy, the physician does.