Chapter 58
1. When preparing an educational program on autoimmune disorders, the nurse should
include the following topics:
Select all that apply.
1. Rheumatoid arthritis (RA)
2. Scleroderma
3. Systemic lupus erythematosus (SLE)
4. Gouty arthritis
5. Reactive arthritis
Answer: 1. Rheumatoid arthritis (RA)
2. Scleroderma
3. Systemic lupus erythematosus (SLE)
Rationale:
Rheumatoid arthritis (RA). Rheumatoid arthritis (RA) is an autoimmune disorder.
Scleroderma. Sclerodermais an autoimmune disorder. Systemic lupus erythematosus (SLE).
Systemic lupus erythematosus (SLE) is an autoimmune disorder. Gouty arthritis. Gouty
arthritis is a connective tissue disorder. Reactive arthritis. Reactive arthritis is a connective
tissue disorder.
2. Rheumatoid arthritis (RA) is a chronic, progressive autoimmune disorder but the nurse is
aware that early, appropriate interventions may play a large role in managing the disease by:
1. Controlling pain generated by the disorder.
2. Reducing affected joint deformity.
3. Minimizing tissue and joint damage.
4. Maintaining optimum level of joint movement.
5. Bringing about a long-term remission of symptoms.
Answer: 1. Controlling pain generated by the disorder.
2. Reducing affected joint deformity.
3. Minimizing tissue and joint damage.
4. Maintaining optimum level of joint movement.
Rationale:
Controlling pain generated by the disorder. Certain measures are used to control this disease
and treat symptoms, such as pain control. Reducing affected joint deformity. Certain
measures are used to control this disease, such as reducing joint deformity. Minimizing tissue
and joint damage. Certain measures are used to control this disease and treat symptoms, such
as reducing damage to joints. Maintaining optimum level of joint movement. Certain
measures are used to control this disease and treat symptoms, such as maintaining joint
function. Bringing about a long-term remission of symptoms. RA is a chronic condition
without a cure or long-term remission.
3. A client diagnosed with gouty arthritis is prescribed the drug colchicine to decrease the
symptoms he is experiencing. When educating the client regarding this medication, the nurse
includes that:
1. Vomiting and/or diarrhea can result with frequent use.
2. A reduction of pain by 60% to 75% is typically experienced.
3. A less restrictive high-purine diet may be adopted.
4. There is a possibility of orthostatic hypotension.
Answer: Vomiting and/or diarrhea can result with frequent use.
Rationale:
Research has shown that for patients who had taken colchicine, there was a reduction of pain
by 34%. However, all patients on colchicine (100%) developed gastrointestinal (GI)
symptoms of vomiting and/or diarrhea due to the frequency necessary to reduce pain,
swelling, and other symptoms causing the gout attack. Encouraging patients to maintain a
low-purine diet and avoid excessive use of alcohol in order to prevent an acute attack may be
a better alternative for the patient. Orthostatic hypotension is not a typical side effect of
colchicines.
4. A nurse has completed a health assessment physical examination and interview at a local
health clinic. Which of the following assessment data would support the client’s diagnosis of
reactive arthritis?
Select all that apply.
1. Client reports having “food poisoning” 12 days ago.
2. Urination results in a painful sensation.
3. Conjunctiva of right eye is reddened, with a thin watery drainage.
4. Serum creatinine increasing from 0.9 to 1.1 mg/dl.
5. Serum potassium 3.5 mM.
Answer: 1. Client reports having “food poisoning” 12 days ago.
2. Urination results in a painful sensation.
3. Conjunctiva of right eye is reddened, with a thin watery drainage.
4. Serum creatinine increasing from 0.9 to 1.1 mg/dl.
Rationale:
Client reports having “food poisoning” 12 days ago. Assessment data supporting a diagnosis
of reactive arthritis would include gastrointestinal bacterial infection occurring 1 to 3 weeks
prior to the outbreak of symptoms. Urination results in a painful sensation. Assessment data
supporting a diagnosis of reactive arthritis would include symptoms associated with
urethritis. Conjunctiva of right eye is reddened, with a thin watery drainage. Assessment data
supporting a diagnosis of reactive arthritis would include symptoms associated with these eye
conditions. Serum creatinine increasing from 0.9 to 1.1 mg/dl. Diagnostic lab testing would
reveal an increasing serum creatinine level. Serum potassium 3.5 mM. Diagnostic lab testing
would reveal a serum potassium level that is elevated (> 5.0 mM).
5. The nurse assessing a client who has been diagnosed with Lyme disease in its early stage
recognizes the following symptoms as classically seen in that stage:
Select all that apply.
1. “Bull’s eye” rash
2. Stiff neck
3. Forgetfulness
4. Severe headache
5. Painful urination
Answer: 1. “Bull’s eye” rash
2. Stiff neck
3. Forgetfulness
Rationale:
“Bull’s eye” rash. Assessment of the early localized disease, the first stage, which occurs
between days 7 and 10, includes evaluating for a growing rash called erythema chronicum
migrans (ECM). ECM looks like a bull’s eye on the affected part. Stiff neck. The early
localized disease symptoms include stiff neck. Forgetfulness. The early localized disease
symptoms include forgetfulness. Severe headache. The early localized disease symptoms
include headache. Painful urination. Painful urination is not symptom of any stage of Lyme’s
disease.
6. The nurse caring for a client who is a smoker, was diagnosed with scleroderma, and has
been experiencing esophageal irritation and heartburn includes the following interventions
into the client’s plan of care:
Select all that apply.
1. Elevate head of the bed to 30 degrees.
2. Reapply nicotine patch as prescribed.
3. Provide decaffeinated beverages only.
4. Administer omeprazole (Prilosec) as prescribed.
5. Provide six small meals daily.
Answer: 1. Elevate head of the bed to 30 degrees.
2. Reapply nicotine patch as prescribed.
3. Provide decaffeinated beverages only.
4. Administer omeprazole (Prilosec) as prescribed.
Rationale:
Elevate head of the bed to 30 degrees. Elevating the head of the bed can reduce the backflow
of acid into the esophagus that causes inflammation and heartburn. Reapply nicotine patch as
prescribed. Avoiding cigarette smoking helps. Provide decaffeinated beverages only.
Avoiding caffeine helps. Administer omeprazole (Prilosec) as prescribed . Medications used
to treat esophagus irritation and heartburn include omeprazole (Prilosec). Provide six small
meals daily. The client’s heartburn will not be positively affected by frequent, small meals.
7. A nurse is preparing a flyer on rheumatoid arthritis (RA) for distribution during a
community health fair. The nurse includes the following facts:
1. Women are three times more likely to be affected.
2. Onset generally occurs between 20 and 40 years of age.
3. Rheumatoid arthritis appears to have a genetic component.
4. Rheumatoid arthritis is the most common form of arthritis.
5. Rheumatoid arthritis typically affects weight-bearing joints.
Answer: 1. Women are three times more likely to be affected.
2. Onset generally occurs near 20 to 40 years of age.
3. Rheumatoid arthritis appears to have a genetic component.
Rationale:
Women are three times more likely to be affected. RA is noted worldwide as affecting three
times more women than men. Onset generally occurs near 20 to 40 years of age. RA can
occur at any age, with the peak incidence being between ages 20 and 40. Rheumatoid arthritis
appears to have a genetic component. RA is thought to be an autoimmune disorder that not
only involves tissue hypersensitivity but also has a genetic component. Rheumatoid arthritis
is the most common form of arthritis. Osteoarthritis (OA) is the most common form of
arthritis. Rheumatoid arthritis typically affects weight-bearing joints. Osteoarthritis (OA) is a
chronic condition that accompanies aging, most commonly affecting weight-bearing joints.
8. A client is receiving a series of diagnostic tests to confirm the diagnosis of osteoarthritis
(OA). The nurse recognizes that the following results tend to support the presence of OA:
Select all that apply.
1. Dexa scan showed increased bone density
2. Increased erythrocyte sedimentation rate (ESR) in blood
3. Bone spurs visible on computed tomography (CT)
4. Asymmetrical joint cartilage loss seen on x-ray
5. Presence of antinuclear antibodies in blood
Answer: 1. Dexa scan showed increased bone density
2. Increased erythrocyte sedimentation rate (ESR) in blood
3. Bone spurs visible on computed tomography (CT)
4. Asymmetrical joint cartilage loss seen on x-ray
Rationale:
Dexa scan showed increased bone density. Increased bone density is a positive diagnostic
result for OA. Increased erythrocyte sedimentation rate (ESR) in blood. Increased erythrocyte
sedimentation rate (ESR) is a positive diagnostic result for OA. Bone spurs visible on
computed tomography (CT). Bone spurs are a positive diagnostic result for OA.
Asymmetrical joint cartilage loss seen on x-ray. Asymmetrical joint cartilage loss is a positive
diagnostic result for OA. Presence of antinuclear antibodies in blood. Presence of antinuclear
antibodies in blood is reflective of RA.
9. The nurse is providing dietary education for a client recently diagnosed with a form of
arthritis. The client is encouraged to avoid alcohol, organ meats, and dried peas, beans, and
peanuts. These recommendations are appropriate for clients diagnosed with:
1. Gouty arthritis.
2. Osteoarthritis.
3. Rheumatoid arthritis.
4. Reactive arthritis.
Answer: Gouty arthritis.
Rationale:
Because gouty arthritis is caused by indulging in foods high in purines, it can be controlled
by eating a well-balanced, low-calorie, low-purine diet and by reducing alcohol consumption.
Foods to be avoided are alcohol, organ meats, and rich foods such as gravies, dried legumes,
and anchovies. Osteoarthritis, rheumatoid arthritis, and reactive arthritis are not affected by
diet as directly as is gouty arthritis.
10. A nurse is discussing the symptomology of osteoarthritis (OA) with a client. The nurse
shows an understanding of the disease process when identifying which of the following as an
initial symptom of the disease?
1. Painful stiffness in the joints of the fingers
2. Popping sensation felt in the wrist joint when typing
3. Knee pain when leg is at rest
4. A fine red rash on the elbow that is constant
Answer: Painful stiffness in the joints of the fingers
Rationale:
The onset of osteoarthritis (OA) is gradual and progressive. The symptoms that are noticed
first are pain and stiffness in the affected joint or joints. Crepitus (grating, crackling, or
popping sounds experienced at a joint) and pain at rest are late signs of OA in a joint. A red
rash is not a typical indicator of OA.
11. A client with a history of rheumatoid arthritis reports mobility impairment as a result of
hip and knee joint stiffness. The nurse suggests the following interventions to assist the client
in managing this problem:
Select all that apply.
1. Encouraging frequent periods of rest for the affected hip and knee joints.
2. Instructing the client in the proper technique for active range of motion of the affected
joints.
3. Educating the client’s family to perform passive range-of-motion exercises of the affected
joints.
4. Suggesting the application of ice to the affected joints to minimize pain.
5. Discussing the use of relaxation techniques when affected joints are most painful.
Answers:
1. Encouraging frequent periods of rest for the affected hip and knee joints.
2. Instructing the client in the proper technique for active range of motion of the affected
joints.
3. Educating the client’s family to perform passive range-of-motion exercises of the affected
joints.
Rationale:
Encouraging frequent periods of rest for the affected hip and knee joints. Rest will help
maintain maximum joint mobility. Instructing the client in the proper technique for active
range of motion of the affected joints. Active range of motion exercises will help maintain
maximum joint mobility. Educating the client’s family to perform passive range-of-motion
exercises of the affected joints. Passive range of motion exercises will help maintain
maximum joint mobility. Suggesting the application of ice to the affected joints to minimize
pain. The application of heat is more appropriate since it will facilitate movement of the
joints while also impacting the inflammatory process. Discussing the use of relaxation
techniques when affected joints are most painful. Relaxation techniques are directed toward
pain management, not joint mobility.
12. Impaired physical mobility is a major nursing diagnosis for clients with osteoarthritis
(OA). The nursing intervention best directed toward addressing this client’s limitation is:
1. Assessing the client’s range of motion of affected joints in order to plan and implement
appropriate interventions.
2. Encouraging consistently high activity levels in order to minimize the development of
associated emotional and self-esteem problems.
3. Encouraging client to assume responsibility for personal self-care needs in order to retain
ability to be physically active.
4. Assessing and managing the client’s need for narcotic analgesics in order to minimize the
impact that pain has on personal activities of daily living.
Answer: Assessing the client’s range of motion of affected joints in order to plan and
implement appropriate interventions.
Rationale:
A determination of the client’s range of motion is needed to provide the best individualized
care. Clients with osteoarthritis (OA) will need to build in periodic rest periods in order to
decrease pain and associated symptoms such as depression once depression is identified in
this client. Realistic goals will need to be set for the client with OA. Assuming responsibility
for personal self-care needs may not be realistic for all clients with OA. Simply encouraging
the client to remain active does not provide comprehensive care. OA is a chronic condition,
and the use of narcotics could lead to dependence.
13. When providing care to the client with an exacerbation of gout resulting in foot pain,
which of the following nursing interventions will aid in promoting comfort?
1. Elevating the extremity using a foot cradle
2. Wrapping the extremity in an ace bandage
3. Encouraging liberal fluid intake
4. Providing passive range-of-motion exercises
Answer: Elevating the extremity using a foot cradle
Rationale:
The pain in the affected extremity will be lessened with elevation; elevation will reduce
inflammation. Wrapping the extremity and range of motion could increase the pain being
experienced. Fluid intake is encouraged, but will not directly reduce the client’s discomfort.
14. A client is experiencing a reoccurrence of the symptoms typical of gout in his right foot.
The nurse shows an understanding of the diagnostic testing appropriate for this client when
preparing the client for a(n):
Select all that apply.
1. Serum uric acid level.
2. Complete blood count (CBC).
3. X-ray of the affected foot.
4. MRI of the affected foot.
5. CT of the affected foot.
Answer: 1. Serum uric acid level.
2. Complete blood count (CBC).
3. X-ray of the affected foot.
Rationale:
Serum uric acid level. An elevated uric acid level greater than7.5 mg/dL is almost always
identified with gout. Complete blood count (CBC). A complete blood count includes a white
blood cell (WBC) count, which shows a significant elevation during an acute attack of gout.
X-ray of the affected foot. An x-ray would be appropriate to assess underlying joint damage,
especially in patients who have had multiple episodes of gouty arthritis. MRI of the affected
foot. An MRI is an expensive test and would not be needed to diagnose gout but could be
ordered to rule out other diagnoses if the typical indicators for gout are not discovered. CT of
the affected foot. A CT is an expensive test and would not be needed to diagnose gout but
could be ordered to rule out other diagnoses if the typical indicators for gout are not
discovered.
15. The nurse preparing discharge medication instructions for a client with a history of
hepatic disease who has been diagnosed with gouty arthritis and prescribed colchicine
includes the following information in the discharge teaching:
Select all that apply.
1. Signs of medication toxicity include diarrhea, anorexia, and weakness.
2. Adverse reactions to the medication include sore throat, bruising, and fever.
3. Take medication as prescribed, but arrange schedule to coincide with meals.
4. Keep scheduled appointments for the monitoring of prothrombin time.
5. Maintain current weight with the inclusion of calorie-dense foods.
Answer: 1. Signs of medication toxicity include diarrhea, anorexia, and weakness.
2. Adverse reactions to the medication include sore throat, bruising, and fever.
3. Take medication as prescribed, but arrange schedule to coincide with meals.
Rationale:
Signs of medication toxicity include diarrhea, anorexia, and weakness. Observe for early
signs of toxicity (colchicine): weakness, anorexia, nausea, vomiting, and diarrhea, especially
in presence of cardiac, renal, or hepatic disease. Adverse reactions to the medication include
sore throat, bruising, and fever. Observe for severe adverse effects: nausea, sore throat or
mouth, fever, fatigue, unusual bleeding, or bruising (bone marrow depression). Take
medication as prescribed but arrange schedule to coincide with meals. Give medications after
a meal to reduce gastric distress. Keep scheduled appointments for the monitoring of
prothrombin time. Prothrombin time is not usually monitored for clients prescribed
colchicines. Maintain current weight with the inclusion of calorie-dense foods. Gouty arthritis
is seen more frequently in clients who are overweight, so the inclusion of calorie-dense foods
would not be encouraged.
16. When preparing an informational sheet on myositis for distribution at a meeting of a
lupus support group, the nurse includes the following facts concerning this disease:
Select all that apply:
1. Myositis contains four different forms of the disorder.
2. Onset for polymyositis (PM) is usually between the ages of 40 and 50.
3. Inclusion body myositis (IBM) is more common in females.
4. Existing autoimmune conditions are a contributing factor in its development.
5. It is a commonly seen immune disorder.
Answer: 1. Myositis contains four different forms of the disorder.
2. Onset for polymyositis (PM) is usually between the ages of 40 and 50.
3. Inclusion body myositis (IBM) is more common in females.
4. Existing autoimmune conditions are a contributing factor in its development.
Rationale:
Myositis contains four different forms of the disorder. There are four kinds of myositis:
polymyositis (PM), dermatomyositis (DM), inclusion body myositis (IBM), and juvenile
myositis (JM). Onset for polymyositis (PM) is usually between the ages of 40 and 50. PM can
occur at any age, but affects those between the ages 40 and 50. Inclusion body myositis
(IBM) is more common in females. IBM typically begins after age 50 and is more common in
women than in men. Existing autoimmune conditions are a contributing factor in its
development. Myositis occurs more readily with patients who have lupus. It is a commonly
seen immune disorder. Myositis is an uncommon disease wherein the immune system
inflames the body’s own healthy muscle tissue. These conditions are usually caused by an
injury, infection, or autoimmune condition.
17. The nurse caring for a client with symptomlogy suggestive of myositis shows an
understanding of the disease when providing the client with information concerning
appropriate diagnostic testing that includes:
Select all that apply.
1. Serum creatine kinase.
2. Electrogram.
3. Magnetic resonance (MI).
4. Echocardiograms.
5. Synovial fluid culture.
Answer: 1. Serum creatine kinase.
2. Electrogram.
3. Magnetic resonance (MI).
Rationale:
Serum creatine kinase. A laboratory test that can assist with the diagnosis of myositis is the
creatine kinase. This test measures autoantibodies and the muscle enzymes. Electrogram. A
diagnostic test that can confirm the diagnosis is the electromyogram to identify the inflamed
muscles. Magnetic resonance (MI). A diagnostic test that also can confirm the diagnosis is
magnetic resonance imaging to identify the inflamed muscles. Echocardiograms.
Echocardiograms are sometimes required to assess cardiac involvement in clients with
scleroderma. Synovial fluid culture. Synovial fluid cultures are appropriate in the diagnosis of
septic arthritis.
18. A client experiencing the typical physical limitations associated with myositis shows the
nurse he is achieving independence by reporting that:
Select all that apply.
1. On a daily basis, he is capable of providing 80% of self-care independently.
2. He has not been injured as a result of a fall in the last 6 months.
3. Nonsteroidal anti-inflammatory medications allow for a pain rating of 3 out of 10.
4. He is considering reducing physical therapy (PT) visits by two visits a month.
5. The rash on his face and neck has diminished drastically.
Answer: 1. On a daily basis, he is capable of providing 80% of self-care independently.
2. He has not been injured as a result of a fall in the last 6 months.
3. Nonsteroidal anti-inflammatory medications allow for a pain rating of 3 out of 10.
Rationale:
On a daily basis, he is capable of providing 80% of self-care independently. Evaluation
parameters include that the patient is able to provide self-care. He has not been injured as a
result of a fall in the last 6 months. Evaluation parameters include that the patient reports no
falls. Nonsteroidal anti-inflammatory medications allow for a pain rating of 3 out of 10.
Evaluation parameters include that the patient has no pain or minimal pain with or without
medications. He is considering reducing physical therapy (PT) visits by two visits a month.
Reducing PT is likely to reduce his capacity to ambulate and to be independent in self-care.
An exercise program may be beneficial to prevent muscle atrophy and promote range of
motion. The rash on his face and neck has diminished drastically. A diminished rash indicates
that his medication therapy is effective, not that he is achieving independence.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
