Chapter 18: Care of Patients with Arthritis and Other Connective Tissue Diseases Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE
... [Show More] 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
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
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
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
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
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 [Show Less]