Chapter 18: Care of Patients with Arthritis and Other Connective Tissue Diseases Nursing School Test Banks

Chapter 18: Care of Patients with Arthritis and Other Connective Tissue Diseases
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

1. A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)?
a. Avoid contact sports.
b. Get plenty of calcium.
c. Lose weight if needed.
d. Engage in weight-bearing exercise.
ANS: C
Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.

DIF: Understanding/Comprehension REF: 294
KEY: Client teaching| health promotion| osteoarthritis| weight loss
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

2. A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?
a. Acetaminophen (Tylenol)
b. Cyclobenzaprine hydrochloride (Flexeril)
c. Hyaluronate (Hyalgan)
d. Ibuprofen (Motrin)
ANS: A
All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

DIF: Remembering/Knowledge REF: 293
KEY: Osteoarthritis| acetaminophen| pharmacologic pain management| patient teaching
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

3. The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most appropriate?
a. Are you compliant with following the diabetic diet?
b. Have you been taking glucosamine supplements?
c. How much exercise do you really get each week?
d. Youre still taking your diabetic medication, right?
ANS: B
All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. Compliant is a word associated with negative images, and the client may deny being noncompliant. Asking how much exercise the client really gets is accusatory. Asking if the client takes his or her medications right? is patronizing.

DIF: Applying/Application REF: 295
KEY: Osteoarthritis| nursing assessment| supplements
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?
a. Needs multiple dental fillings
b. Over age 85
c. Severe osteoporosis
d. Urinary tract infection
ANS: C
Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.

DIF: Remembering/Knowledge REF: 295
KEY: Osteoarthritis| osteoporosis| joint replacement| surgical procedures
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury?
a. Administer mild sedation.
b. Keep all four siderails up.
c. Restrain the clients hands.
d. Use an abduction pillow.
ANS: D
Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the clients mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation.

DIF: Applying/Application REF: 297
KEY: Joint replacement| abduction pillow| musculoskeletal system| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement?
a. Administer preoperative antibiotic as ordered.
b. Assess the clients white blood cell count.
c. Instruct the client to shower the night before.
d. Monitor the clients temperature postoperatively.
ANS: A
To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.

DIF: Applying/Application REF: 296
KEY: Joint replacement| Surgical Care Improvement Project (SCIP)| wound infection| antibiotics MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

7. The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best?
a. Assess neurovascular status in both legs.
b. Elevate the affected leg and apply ice.
c. Prepare to administer pain medication.
d. Try to place the affected leg in abduction.
ANS: A
This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.

DIF: Applying/Application REF: 297
KEY: Nursing assessment| joint replacement| musculoskeletal system
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

8. A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed?
a. Assess the distal circulation in 30 minutes.
b. Change the settings based on range of motion.
c. Raise the lower siderail on the affected side.
d. Remind the client to do quad-setting exercises.
ANS: C
Because the clients leg is strapped into the CPM, if it falls off the bed due to movement, the clients leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

DIF: Applying/Application REF: 301
KEY: Joint replacement| delegation| continuous passive motion machine| unlicensed assistive personnel (UAP)
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

9. After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next?
a. Document the findings and monitor as prescribed.
b. Increase the frequency of monitoring the client.
c. Notify the surgeon or anesthesia provider immediately.
d. Palpate the clients bladder or perform a bladder scan.
ANS: C
With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.

DIF: Applying/Application REF: 302
KEY: Postoperative nursing| joint replacement| nursing assessment| musculoskeletal system
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

10. A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important?
a. Administering pain medication before transport
b. Answering any last-minute questions by the client
c. Ensuring the family has directions to the facility
d. Providing a verbal hand-off report to the facility
ANS: D
As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority.

DIF: Applying/Application REF: 304
KEY: Hand-off communication| communication| The Joint Commission
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

11. A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first?
a. Client who reports jaw pain when eating
b. Client with a red, hot, swollen right wrist
c. Client who has a puffy-looking area behind the knee
d. Client with a worse joint deformity since the last visit
ANS: B
All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.

DIF: Applying/Application REF: 305
KEY: Rheumatoid arthritis| nursing assessment| autoimmune disorder
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

12. A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning from surgery. What action by the nurse is best?
a. Assist the client to change positions.
b. Document the findings in the clients chart.
c. Encourage range of motion of the neck.
d. Notify the provider immediately.
ANS: D
Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.

DIF: Applying/Application REF: 306
KEY: Rheumatoid arthritis| autoimmune disorder| musculoskeletal system| communication| critical rescue MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

13. The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjgrens syndrome?
a. Abdominal assessment
b. Oxygen saturation
c. Renal function studies
d. Visual acuity
ANS: D
Sjgrens syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjgrens syndrome.

DIF: Applying/Application REF: 306
KEY: Rheumatoid arthritis| nursing assessment| musculoskeletal system| visual disturbances| autoimmune disorder| sensory system
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

14. The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met?
a. Attends meetings of a book club
b. Has a positive outlook on life
c. Takes medication as directed
d. Uses assistive devices to protect joints
ANS: A
All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met.

DIF: Evaluating/Synthesis REF: 312
KEY: Rheumatoid arthritis| autoimmune disorder| coping| psychosocial response
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Psychosocial Integrity

15. A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate?
a. Giving subcutaneous injections
b. Having a chest x-ray once a year
c. Taking the medication with food
d. Using heat on the injection site
ANS: A
Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication. The other options are not appropriate for etanercept.

DIF: Understanding/Comprehension REF: 310
KEY: Rheumatoid arthritis| autoimmune disease| biologic response modifiers| client education MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

16. The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first?
a. Client taking celecoxib (Celebrex) and ranitidine (Zantac)
b. Client taking etanercept (Enbrel) with a red injection site
c. Client with a blood glucose of 190 mg/dL who is taking steroids
d. Client with a fever and cough who is taking tofacitinib (Xeljanz)
ANS: D
Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels.

DIF: Applying/Application REF: 311
KEY: Rheumatoid arthritis| autoimmune disorders| nursing assessment| biologic response modifiers MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

17. A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?
a. Heating pad
b. Ice packs
c. Splints
d. Wax dip
ANS: B
Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

DIF: Remembering/Knowledge REF: 311
KEY: Rheumatoid arthritis| autoimmune disorders| ice| pain
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

18. The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further?
a. Creatinine: 3.9 mg/dL
b. Platelet count: 210,000/mm3
c. Red blood cell count: 5.2/mm3
d. White blood cell count: 4400/mm3
ANS: A
Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.

DIF: Applying/Application REF: 314
KEY: Systemic lupus erythematosus| autoimmune disease| renal system
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

19. A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?
a. Assess medication records for steroid use.
b. Facilitate a consultation with physical therapy.
c. Measure the range of motion in both hips.
d. Notify the health care provider immediately.
ANS: A
Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.

DIF: Applying/Application REF: 315
KEY: Systemic lupus erythematosus| autoimmune disorders| nursing assessment| pain| steroids MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

20. A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best?
a. Explain to the client that SLE is an unpredictable disease.
b. Help the client create backup plans to minimize disruption.
c. Offer to talk to the family and educate them about SLE.
d. Tell the client to remain compliant with treatment plans.
ANS: B
SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.

DIF: Applying/Application REF: 316
KEY: Systemic lupus erythematosus| autoimmune disorders| coping| psychosocial response
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

21. A nurse is caring for a client with systemic sclerosis. The clients facial skin is very taut, limiting the clients ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate?
a. Dentist
b. Massage therapist
c. Occupational therapy
d. Physical therapy
ANS: A
With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.

DIF: Applying/Application REF: 317
KEY: Systemic sclerosis| autoimmune disorder| oral care| collaboration
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

22. The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate?
a. Drink 1 to 2 liters of water each day.
b. Have 10 to 12 ounces of juice a day.
c. Liver is a good source of iron.
d. Never eat hard cheeses or sardines.
ANS: A
Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from occurring. Citrus juice is high in ash, which can help prevent the formation of stones, but the value of this recommendation is not clear. Clients with gout should not eat organ meats or fish with bones, such as sardines.

DIF: Understanding/Comprehension REF: 320
KEY: Gout| musculoskeletal system| patient education| nutrition
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

23. A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include?
a. Avoid large crowds or people who are ill.
b. Stay upright for 1 hour after taking this drug.
c. This drug may cause your hair to fall out.
d. You may double the dose if pain is severe.
ANS: A
This drug has a Food and Drug Administration black box warning about opportunistic or other serious infections. Teach the client to avoid large crowds and people who are ill. The other instructions do not pertain to golimumab.

DIF: Applying/Application REF: 321
KEY: Psoriatic arthritis| autoimmune disorders| patient education| biologic response modifiers MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

24. A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started acting up, especially both hips and knees. What action by the nurse is best?
a. Assess the client for the presence of subcutaneous nodules or Bakers cysts.
b. Inspect the clients feet and hands for podagra and tophi on fingers and toes.
c. Prepare to teach the client about an acetaminophen (Tylenol) regimen.
d. Reassure the client that the problems will fade as the weather changes again.
ANS: A
Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Bakers cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.

DIF: Applying/Application REF: 306
KEY: Rheumatoid arthritis| autoimmune disorders| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

25. A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection?
a. Assess the clients white blood cell count.
b. Culture any drainage from the wound.
c. Monitor the clients temperature every 4 hours.
d. Use aseptic technique for dressing changes.
ANS: D
Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.

DIF: Applying/Application REF: 297
KEY: Joint replacement| infection control| wound infection| dressings
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

26. A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management?
a. I can bend down to pick something up.
b. I no longer need to do my exercises.
c. I will not sit with my legs crossed.
d. I wont wash my incision to keep it dry.
ANS: C
There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.

DIF: Evaluating/Synthesis REF: 298
KEY: Joint replacement| discharge planning/teaching| nursing evaluation
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Health Promotion and Maintenance

27. The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse?
a. Checking to see if the machine is working
b. Keeping controls in a secure place on the bed
c. Placing padding in the machine per request
d. Storing the CPM machine under the bed after removal
ANS: D
For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.

DIF: Applying/Application REF: 302
KEY: Joint replacement| continuous passive motion machine| infection control| delegation
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

28. A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement?
a. I always wear long sleeves, pants, and a hat when outdoors.
b. I try not to use cosmetics that contain any type of sunblock.
c. Since I tend to sweat a lot, I use a lot of baby powder.
d. Since I cant be exposed to the sun, I have been using a tanning bed.
ANS: A
Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.

DIF: Evaluating/Synthesis REF: 316
KEY: Systemic lupus erythematosus| nursing evaluation| self-care| patient teaching| integumentary system
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Health Promotion and Maintenance

29. A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important?
a. Administer preoperative medications as prescribed.
b. Ensure that a consent for transfusion is on the chart.
c. Explain to the client how anemia affects healing.
d. Teach the client about foods high in protein and iron.
ANS: B
The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

DIF: Applying/Application REF: 296
KEY: Joint replacement| informed consent| blood transfusions| preoperative nursing
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

30. An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate?
a. Instruct the client to avoid large crowds.
b. Prepare to administer epoetin alfa (Epogen).
c. Teach the client about foods high in iron.
d. Tell the client that all laboratory results are normal.
ANS: B
This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the clients red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The clients white blood cell count is normal, so avoiding infection is not the priority.

DIF: Applying/Application REF: 296
KEY: Joint replacement| anemia| colony-stimulating factors| nursing intervention
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

31. A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important?
a. Have adequate help to transfer the client.
b. Provide socks so the client can slide easier.
c. Tell the client full weight bearing is allowed.
d. Use a footstool to elevate the clients leg.
ANS: A
The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

DIF: Applying/Application REF: 299
KEY: Joint replacement| safety| falls| musculoskeletal system
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

32. A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best?
a. A little sedation will help you get some rest.
b. Depression often accompanies fibromyalgia.
c. This drug works in the brain to decrease pain.
d. You will have more energy after taking this drug.
ANS: C
Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.

DIF: Understanding/Comprehension REF: 322
KEY: Fibromyalgia| antidepressants| pain| pharmacologic pain management
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

33. A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best?
a. Assess the clients culture more thoroughly.
b. Discuss options for performing duties.
c. See if the client will call a community meeting.
d. Suggest the client give up the role of elder.
ANS: A
The nurse needs a more thorough understanding of the clients culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.

DIF: Applying/Application REF: 313
KEY: Rheumatoid arthritis| autoimmune disorders| coping| culture| patient-centered care| diversity MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

34. A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?
a. Lets ask the provider about increasing your pain pills.
b. Hold ice bags against your hands before quilting.
c. Try a paraffin wax dip 20 minutes before you quilt.
d. You need to stop quilting before it destroys your fingers.
ANS: C
Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a hot or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.

DIF: Applying/Application REF: 311
KEY: Rheumatoid arthritis| autoimmune disorders| nonpharmacologic pain management| heat MSC: Integrated Process: Caring
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

35. A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important?
a. Be sure you get enough sleep at night.
b. Eat plenty of high-protein, high-iron foods.
c. Notify your provider at once if you get a fever.
d. Weigh yourself every day on the same scale.
ANS: C
Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement.

DIF: Understanding/Comprehension REF: 315
KEY: Systemic lupus erythematosus| autoimmune disorders| patient education| self-care| fever MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

36. A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberdens nodules. What assessment technique is correct?
a. Inspect the clients distal finger joints.
b. Palpate the clients abdomen for tenderness.
c. Palpate the clients upper body lymph nodes.
d. Perform range of motion on the clients wrists.
ANS: A
Herberdens nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the clients distal fingertips. These nodules are not found in the abdomen, lymph nodes, or wrists.

DIF: Applying/Application REF: 292
KEY: Musculoskeletal system| musculoskeletal assessment| nursing assessment| osteoarthritis MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance

37. A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best?
a. Consult with the health care provider about administering both drugs to the client.
b. Inform the client that the celecoxib will be started when he or she goes home.
c. Teach the client that, since morphine is stronger, celecoxib is not needed.
d. Tell the client he or she should not take both drugs at the same time.
ANS: A
Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

DIF: Applying/Application REF: 293
KEY: Postoperative nursing| nonsteroidal anti-inflammatory drugs (NSAIDs)| musculoskeletal disorders
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

MULTIPLE RESPONSE

1. The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.)
a. It affects single joints only.
b. Antibodies lead to inflammation.
c. It consists of an autoimmune process.
d. Morning stiffness is rare.
e. Permanent damage is inevitable.
ANS: B, C
RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.

DIF: Remembering/Knowledge REF: 304
KEY: Rheumatoid arthritis| musculoskeletal system| autoimmune disorder
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.)
a. Avoid acetaminophen in over-the-counter medications.
b. It may take several weeks to become effective on pain.
c. Pregnancy and breast-feeding are not affected by MTX.
d. Stay away from large crowds and people who are ill.
e. You may find that folic acid, a B vitamin, reduces side effects.
ANS: A, B, D, E
MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.

DIF: Applying/Application REF: 308
KEY: Rheumatoid arthritis| autoimmune disease| patient education| disease-modifying antirheumatic drugs (DMARDs)| acetaminophen
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

3. A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.)
a. Acupuncture
b. Stretching
c. Supplements
d. Tai chi
e. Vigorous aerobics
ANS: A, B, D
There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.

DIF: Remembering/Knowledge REF: 322
KEY: Fibromyalgia| patient education| physical modalities| nonpharmacologic pain management| complementary and alternative therapies
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

4. The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.)
a. Anorexia
b. Feltys syndrome
c. Joint deformity
d. Low-grade fever
e. Weight loss
ANS: B, C, E
Late manifestations of RA include Feltys syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

DIF: Remembering/Knowledge REF: 305
KEY: Rheumatoid arthritis| nursing assessment| musculoskeletal system| autoimmune disorders MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

5. An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Apply an abduction pillow to the clients legs.
b. Assess the skin under the abduction pillow straps.
c. Place pillows under the heels to keep them off the bed.
d. Monitor cognition to determine when the client can get up.
e. Take and record vital signs per unit/facility policy.
ANS: A, C, E
The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurses responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility.

DIF: Applying/Application REF: 297
KEY: Joint replacement| delegation| abduction pillow| unlicensed assistive personnel (UAP)| nursing assessment
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

6. The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.)
a. Dry, scaly skin rash Systemic lupus erythematosus (SLE)
b. Esophageal dysmotility Systemic sclerosis
c. Excess uric acid excretion Gout
d. Footdrop and paresthesias Osteoarthritis
e. Vasculitis causing organ damage Rheumatoid arthritis
ANS: A, B, E
A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and paresthesias occur in rheumatoid arthritis.

DIF: Remembering/Knowledge REF: 305, 314, 317
KEY: Autoimmune disorders
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctly matched? (Select all that apply.)
a. Allopurinol (Zyloprim) Acute gout
b. Colchicine (Colcrys) Acute gout
c. Febuxostat (Uloric) Chronic gout
d. Indomethacin (Indocin) Acute gout
e. Probenecid (Benemid) Chronic gout
ANS: B, C, D, E
Acute gout can be treated with colchicine and indomethacin. Chronic gout can be treated with febuxostat and probenecid. Allopurinol is used for chronic gout.

DIF: Remembering/Knowledge REF: 320
KEY: Gout| pain| pharmacologic pain management
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

8. The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Collaborate with a registered dietitian for appropriate foods.
b. Inspect the skin and note any areas of ulceration.
c. Keep the room at a comfortably warm temperature.
d. Place a foot cradle at the end of the bed to lift sheets.
e. Remind the client to elevate the head of the bed after eating.
ANS: C, D, E
The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynauds phenomenon. The UAP can adjust the room temperature for the clients comfort. Keeping the sheets off the feet will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can remind the client of this once he or she has been taught. The other actions are performed by the registered nurse.

DIF: Applying/Application REF: 315
KEY: Systemic scleroderma| autoimmune disorders| delegation| nonpharmacologic pain management MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

9. A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.)
a. Grab bars to reach high items
b. Long-handled bath scrub brush
c. Soft rocker-recliner chair
d. Toothbrush with built-up handle
e. Wheelchair cushion for comfort
ANS: A, B, D
Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.

DIF: Applying/Application REF: 311
KEY: Rheumatoid arthritis| autoimmune disorders| activities of daily living| musculoskeletal system| functional ability MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

10. A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.)
a. Buy and install an elevated toilet seat.
b. Install grab bars in the shower and by the toilet.
c. Step into the bathtub with the affected leg first.
d. Remove all throw rugs throughout the house.
e. Use a shower chair while taking a shower.
ANS: A, B, D, E
Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

DIF: Applying/Application REF: 301
KEY: Joint replacement| osteoarthritis| home safety| assistive devices
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

11. A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.)
a. Allow the client uninterrupted rest time.
b. Assess the clients usual bedtime routine.
c. Limit environmental noise as much as possible.
d. Offer a massage or warm shower at night.
e. Request an order for a strong sleeping pill.
ANS: A, B, C, D
Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the clients usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.

DIF: Applying/Application REF: 322
KEY: Fibromyalgia| rest and sleep| patient-centered care
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

12. A client has a possible connective tissue disease and the nurse is reviewing the clients laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select all that apply.)
a. Elevated antinuclear antibody (ANA) Normal value; no connective tissue disease
b. Elevated sedimentation rate Rheumatoid arthritis
c. Lowered albumin Indicative only of nutritional deficit
d. Positive human leukocyte antigen B27 (HLA-B27) Reiters syndrome or ankylosing spondylitis
e. Positive rheumatoid factor Possible kidney disease
ANS: D, E
The HLA-B27 is diagnostic for Reiters syndrome or ankylosing spondylitis. A positive rheumatoid factor can be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation.

DIF: Remembering/Knowledge REF: 307
KEY: Autoimmune disorders| laboratory values
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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