Chapter 65: Arthritis and Connective Tissue Diseases NCLEX – Flashcards
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In assessing the joints of a patient with rheumatoid arthritis, the nurse understands that the joints are damaged by (select all that apply)
a. bony ankylosis following inflammation of the joints
b. the deterioration of cartilage by proteolytic enzymes
c. the development of Heberden's nodes in the joint capsule
d.. increased cartilage and bony growth at the joint margins
e. invasion of pannus into the joint causing a loss of cartilage
answer
Correct answers: a, e
Rationale: Bony ankylosis is the union of the bones of a joint by proliferation of bone cells, resulting in complete immobility. Bony ankylosis occurs with advanced rheumatoid arthritis. Joint changes from chronic inflammation begin when the hypertrophied synovial membrane invades the surrounding cartilage, ligaments, tendons, and joint capsule. Pannus (i.e., highly vascular granulation tissue) forms within the joint. It eventually covers and erodes the entire surface of the articular cartilage. The production of inflammatory cytokines at the pannus-cartilage junction further contributes to cartilage destruction. The pannus scars and shortens supporting structures such as tendons and ligaments, ultimately causing joint laxity, subluxation, and contracture.
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Assessment data in the patient with osteoarthritis commonly include
a. gradual weight loss
b. elevated WBC count
c. joint pain that worsens with use
d. straw-colored synovial fluid
answer
Correct answer: c
Rationale: Osteoarthritis pain ranges from mild discomfort to significant disability. Joint pain is the predominant symptom, and the pain generally worsens with joint use.
question
Teach the patient with ankylosing spondylitis the importance of
a. regular exercise and maintaining proper posture
b. continuing with physical activity during flare-ups
c. avoiding extremes in environmental temperatures
d. applying cool compresses for relief of local symptoms
answer
Correct answer: a
Rationale: Patients with ankylosing spondylitis (AS) should exercise after pain and stiffness are managed. Postural control is important to minimize spinal deformity. The exercise regimen should include back, neck, and chest stretches. The nurse should educate the patient with AS about regular exercise and attention to posture, local moist-heat applications, and knowledgeable use of drugs. The nurse should discourage excessive physical exertion during periods of active flare-up of the disease. Proper positioning at rest is essential. The mattress should be firm, and the patient should sleep on the back with a flat pillow, avoiding positions that encourage flexion deformity. Postural training emphasizes avoiding spinal flexion (e.g., leaning over a desk), heavy lifting, and prolonged walking, standing, or sitting.
question
When administering medications to the patient with gout, the nurse would recognize which of the following as a treatment for chronic disease?
a. Colchicine
b. Febuxostat
c. Sulfasalazine
d. Cyclosporine
answer
Correct answer: b
Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for long-term management of hyperuricemia in persons with chronic gout. Acute gouty arthritis is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs).
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In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes
a. circulating immune complexes formed from IgG autoantibodies reacting with IgG
b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer
c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles
d. the production of a variety of autoantibodies directed against components of the cell nucleus
answer
Correct answer: d
Rationale: Systemic lupus erythematosus (SLE) is characterized by the production of many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins. Autoimmune reactions characteristically are directed against constituents of the cell nucleus (e.g., antinuclear antibodies [ANAs]), particularly DNA. Circulating immune complexes containing antibody against DNA are deposited in the basement membranes of capillaries in the kidneys, heart, skin, brain, and joints. Complement is activated, and inflammation occurs. The overaggressive antibody response is also related to activation of B and T cells. The specific manifestations of SLE depend on which cell types or organs are involved. SLE is a type III hypersensitivity response.
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When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to (select all that apply)
a. avoiding the consumption of high-purine foods
b. strategies for good dental hygiene and mouth care
c. protecting the extremities from hot and cold temperatures
d. maintaining joint function and preserving muscle strength
e. performing mouth excursion (yawning) exercises on a daily basis
answer
Correct answers: b, c, d, e
Rationale: Systemic sclerosis (SS), or scleroderma, is a disorder of connective tissue characterized by fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs. The nurse should include the following in the teaching plan for a patient with SS: daily oral hygiene (neglect may increase tooth and gingival problems); protection of hands and feet from cold exposure and possible burns or cuts (wounds heal slowly); avoidance of emotional stress and cold ambient temperatures (they aggravate Raynaud's phenomenon); isometric exercises for arthropathy (no joint movement occurs); use of assistive devices as appropriate and organization of activities to preserve strength and reduce disability; and mouth excursion (i.e., yawning with an open mouth) (helps maintain temporomandibular joint function).
question
In teaching a patient with chronic fatigue syndrome (CFS) about this disorder, the nurse understands that
a. palpating tender points is an indicator of CFS severity
b. many symptoms are similar to fibromyalgia syndrome
c. definitive treatment includes low-dose hydrocortisone
d. CFS is characterized by progressive memory impairment
answer
Correct answer: b
Rationale: Fibromyalgia syndrome (FS) and chronic fatigue syndrome (CFS) have several commonalities. Both occur in previously healthy, young, and middle-aged women; the cause of both includes an infectious trigger, dysfunction of the hypothalamic-pituitary-adrenal axis or an alteration in central nervous system; and common clinical manifestations are malaise and fatigue, cognitive dysfunction, headaches, sleep disturbances, depression, anxiety, fever, and generalized musculoskeletal pain. Both diseases have symptoms that fluctuate over time, and both disorders have no definitive laboratory tests or joint and muscle examinations. They remain diagnoses of exclusion. Treatment for both disorders is symptomatic and may include antidepressant drugs. Other measures are heat, massage, regular stretching, biofeedback, stress management, and relaxation training.
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The nurse is working with a 73-year-old patient with osteoarthritis (OA). In assessing the patient's understanding of this disorder, the nurse concludes teaching has been effective when the patient describes the condition as which of the following?
A. Joint destruction caused by an autoimmune process
B. Degeneration of articular cartilage in synovial joints
C. Overproduction of synovial fluid resulting in joint destruction
D. Breakdown of tissue in non-weight-bearing joints by enzymes
answer
Correct answer: B. Degeneration of articular cartilage in synovial joints
Rationale: OA is a degeneration or breakdown of the articular cartilage in synovial joints. The condition has also been referred to as degenerative joint disease.
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The nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes which of the following activity patterns?
A. Bed rest with bathroom privileges
B. Daily high-impact aerobic exercise
C.A regular exercise program of walking
D. Frequent rest periods with minimal exercise
answer
Correct answer: C. A regular exercise program of walking
Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in the patient with osteoarthritis.
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The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Which of the following findings would the nurse expect to be present on examination of the patient's knees?
A. Ulnar drift
B. Pain with joint movement
C. Reddened, swollen affected joints
D. Stiffness that increases with movement
answer
Correct answer: B. Pain with joint movement
Rationale: OA is characterized predominantly by joint pain upon movement and is a classic feature of the disease.
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The nurse is caring for a patient who has osteoarthritis (OA) of the knees. The nurse teaches the patient that the most beneficial measure to protect the joints is to do which of the following?
A. Use a wheelchair to avoid walking as much as possible.
B. Eat a well-balanced diet to maintain a healthy body weight.
C. Incorrect Use a walker for ambulation to relieve the pressure on her hips.
D. Sit in chairs that do not cause her hips to be lower than her knees.
answer
Correct answer: B. Eat a well-balanced diet to maintain a healthy body weight.
Rationale: Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight.
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The nurse is reinforcing general health teaching with a 64-year-old patient with osteoarthritis (OA) of the hip. Which of the following points would the nurse include in this review of the disorder (select all that apply)?
A. OA cannot be successfully treated with any current therapy options.
B. OA is an inflammatory disease of the joints that may present symptoms at any age.
C.Joint degeneration with pain and disability occurs in the majority of people by the age of 60.
D. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling.
E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication.
answer
Correct answer: D. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling.
E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication.
Rationale: OA occurs with greater frequency with increasing age, but it usually remains confined to a few joints and can be managed with a combination of exercise, diet, and medication. OA can lead to significant disability.
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When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which of the following statements?
A. "I should take the Celebrex as prescribed to help control the pain."
B. "I should try to stay standing all day to keep my joints from becoming stiff."
C. "I can use a cane if I find it helpful in relieving the pressure on my back and hip."
D. "A warm shower in the morning will help relieve the stiffness I have when I get up."
answer
Correct answer: B. "I should try to stay standing all day to keep my joints from becoming stiff."
Rationale: It is important to maintain a balance between rest and activity to prevent overstressing the joints with OA.
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Which of the following patient statements most clearly suggests a need to assess the patient for ankylosing spondylitis (AS)?
A. "My right elbow has become red and swollen over the last few days."
B. "I wake up stiff every morning and my knees just don't want to bend."
C. "My husband tells me that my posture has become so stooped this winter."
D. "My lower back pain seems to be getting worse all the time and nothing seems to help."
answer
Correct answer: D. "My lower back pain seems to be getting worse all the time and nothing seems to help."
Rationale: AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.
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A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease?
A. "I'll try my best to stay out of the sun this summer."
B. "I know that I probably have a high chance of getting arthritis."
C. "I'm hoping that surgery will be an option for me in the future."
D. "I understand that I'm going to be vulnerable to getting infections."
answer
Correct answer: C. "I'm hoping that surgery will be an option for me in the future."
Rationale: SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.
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A 60-year-old woman has pain on motion in her fingers and asks the nurse whether this is just a result of aging. The best response by the nurse includes the information that
a. joint pain with functional limitation is a normal change that affects all people to some extent
b. joint pain that develops with age is usually related to previous trauma or infection of the joints
c. this is a symptom of a systemic arthritis that eventually affects all joints as the disease progresses
d. changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age
answer
D. changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age.
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To preserve function and the ability to perform activities of daily living, the nurse teaches the patient with OA to
a. avoid exercise that involves the affected joints
b. plan and organize less stressful ways to perform tasks
c. maintain normal activities during an acute episode to prevent loss of function
d. use mild analgesics to control symptoms when performing tasks that cause pain
answer
B. plan and organize less stressful ways to perform tasks
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A patient with OA uses NSAIDs to decrease pain and inflammation. The nurse teaches the patient that common side effects of these drugs include
a. allergic reactions, fever, and oral lesions
b. fluid retention, hypertension, and bruising
c. skin rashes, gastric irritation, and headache
d. prolonged bleeding time, blood dyscrasias, and hepatic damage
answer
C. skin rashes, gastric irritation, and headacche
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A patient with OA asks the nurse whether he could try glucosamine and chondroitin for control of his symptoms. The best response by the nurse includes the information that
a. some patients find these supplements helpful for relieving arthritis knee pain and improving mobility
b. although these substances may not help, there is no evidence that they can cause any untoward effects
c. these supplements are a fad that has not been shown to reduce pain or increase joint mobility in patients with OA
d. only dosages of these supplements available by prescription are high enough to provide any benefit in treatment of OA
answer
A. Some patients find these supplements helpful for relieving arthritis knee pain and improving mobilitiy
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A patient taking ibuprofen (Motrin) for treatment of OA has good pain relief but is experiencing increased dyspepsia and nausea with the drug's use. The nurse consults the patient's primary care provider about
a. adding misoprostol (Cytotec) to the patient's drug regimen
b. substituting naproxen (Naprosyn) for the ibuprofen (Motrin)
c. administering the ibuprofen with antacids to decrease the GI irritation
d. returning to the use of acetaminophen, but at a dose of 5 g/day instead of 4 g/day
answer
A. adding misoprostol (Cytotec) to the patient's drug regimen
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The basic pathophysiologic process of rheumatoid arthritis (RA) is
a. destruction of joint cartilage and bones by an autoimmune process
b. initiated by a viral infection that destroys the synovial membranes of joints
c. the presence of HLA-DR4 antigen that causes inflammatory responses throughout the body
d. an immune response that activates complement and produces inflammation of joints and other organ systems
answer
D. an immune response that activates complement and produces inflammation of joints and other organ systems
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During the physical assessment of the patient with moderate RA, the nurse would expect to find
a. hepatomegaly
b. Heberden's nodes
c. spindle-shaped fingers
d. crepitus on joint movement
answer
C. spindle-shaped fingers
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Laboratory findings that the nurse would expect to be present in the patient with RA include
a. polycythemia
b. increased IgG
c. decreased WBC
d. increased C-reactive protein (CRP)
answer
D. increased C-reactive protein (CRP)
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A 70-year old patient is being evaluated for symptoms of RA. The nurse recognizes that a major problem in the management of RA in the older adult is that
a. RA is usually more severe in older adults
b. older patients are not as likely to comply with treatment regimens
c. drug interactions and toxicity are more likely to occur with multidrug therapy
d. laboratory and other diagnostic tests are not effective in identifying RA in older adults
answer
C. drug interactions and toxicity are more likely to occur with multidrug therapy
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After teaching a patient with RA about the prescribed therapeutic regimen, the nurse determines that further instruction is needed when the patient says,
a. it is important for me to perform my prescribed exercises every day
b. I should perform most of my daily chores in the morning when my energy level is highest
c. an ice pack to a joint for 10 minutes may help relieve pain and inflammation when I have an acute flare
d. I can use assistive devices such as padded utensils, electric can openers, and elevated toilet seats to protect my joints
answer
B. I should perform most of my daily chores in the morning when my energy level is highest
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A patient recovering from an acute exacerbation of RA tells the nurse she is too tired to bathe. The nurse should
a. give the patient a bed bath to conserve her energy
b. allow the patient a rest period before showering with the nurses' help
c. tell the patient that she can skip bathing if she will walk in the hall later
d. inform the patient that it is important for her to maintain self-care activities
answer
B. allow the patient a rest period before showering with the nurses' help
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After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when the patient says,
a. heat treatments should not be used if muscle spasms are present
b. cold applications can be applied for 15-20 minutes to relieve joint stiffness
c. I should use heat applications for 20 minutes to relieve the symptoms of an acute flare
d. when my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain
answer
D. when my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relive the pain
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The nurse teaches the patient with RA that one of the most effective methods of aerobic exercise is
a. ballet dancing
b. casual walking
c. aquatic exercises
d. low-impact aerobic exercises
answer
C. aquatic exercises
question
Characteristics of spondyloarthritides associated with HLA-B27 antigen include
a. symmetric polyarticular arthritis
b. an absence of extraarticular disease
c. presence of rheumatoid factor and autoantibodies
d. high level of involvement of sacroiliac joints and the spine
answer
D. high level of involvement is sacroiliac joints and the spine
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An important nursing intervention for the patient with ankylosing spondylitis is to teach the patient to
a. wear roomy shoes with good orthotic support
b. sleep on the side with the knees and hips flexed
c. keep the spine slightly flexed while sitting, standing, or walking
d. perform back, neck, and chest stretches and deep breathing exercises
answer
D. perform back, neck and chest stretches and deep breathing exercises
question
A patient is seen at the outpatient clinic for a sudden onset of inflammation and severe pain in the great toe. A diagnosis of gout is made on the basis of
a. a family history of gout
b. elevated urine uric acid levels
c. elevated serum uric acid levels
d. the presence of sodium urate crystals in synovial fluid
answer
D. the presence of sodium urate cystals in synovial fluid
question
During treatment of the patient with an acute attack of gout, the nurse would expect to administer
a. aspirin
b. colchicine
c. allopurinol (Zyloprim)
d. probenecid (Benemid)
answer
B. Colchicine
question
A patient with gout is treated with drug therapy to prevent future attacks. The nurse teaches the patient that is is the most important to
a. avoid all foods high in purine, such as organ meats
b. have periodic determination of serum uric acid levels
c. perform active ROM of all joints that have been affected by gout
d. increase the dosage of medication with the onset of an acute attack
answer
B. have periodic determination of serum uric acid levels
question
The pathophysiology of systemic lupus erthematosus (SLE) is characterized by
a. destruction of nucleic acids and other self-proteins by autoantibodies
b. overproduction of collagen that disrupts the functioning of internal organs
c. formation of abnormal IgG that attaches to cellular antigens, activating complement
d. increased activity of T-suppressor cells with B-cell hypoactivity, resulting in an immunodeficiency
answer
A. destruction of nucleic acids and other self-proteins by autoantibodies
question
A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. The best response by the nurse is
a. You can plan to have a near-normal life since SLE rarely causes death
b. it is difficult to tell because to disease is so variable in its severity and progression
c. life span is shortened somewhat in people with SLE, but the disease can be controlled with long-term use of corticosteroids
d. most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage
answer
B. it is difficult to tell because the disease is so variable in its severity and progression
question
During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the steroids to begin to be tapered when serum laboratory results indicate
a. increased RBCs
b. decreased ESR
c. decreased anti-DNA
d. increased complement
answer
C. decreased anti-DNA
question
Teaching that the nurse will plan for the patient with SLE includes
a. ways to avoid exposure to sunlight
b. increasing dietary protein and carbohydrate intake
c. the necessity of genetic counseling before planning a family
d. the use of no pharmacologic pain interventions instead of analgesics
answer
A. ways to avoid exposure to sunlight
