A
B
C
D
E
100
The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient’s choice of which food item indicates an understanding of the instructions?
a. Eggs
b. Liver
c. Salmon
d. Chicken
a. Eggs
Rationale: Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.
100
The patient developed acute gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout?
a. Decrease fluid intake
b. Drink a glass of wine daily
c. Administration of probenecid
d. Administration of allopurinol
d. Administration of allopurinol
Rationale: To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the patient’s aspirin will inactivate its effect, resulting in urate retention. Dietary restrictions that limit alcohol and foods high in purine help minimize uric acid production.
100
Four patients have been newly diagnosed with connective tissue disorders. The nurse is concerned with safety issues and interstitial lung involvement for the patient with which diagnosis?
a. Polymyositis
b. Reactive arthritis
c. Sjögren’s syndrome
d. Systemic lupus erythematosus (SLE)
a. Polymyositis
Rationale: Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient’s risk of falls and injury. Weakened pharyngeal muscles also increase the risk for aspiration, with interstitial lung disease in up to 65% of patients. Safety concerns and interstitial lung involvement are not associated with reactive arthritis (Reiter’s syndrome) or Sjögren’s syndrome. Safety may be an issue later in disease progression of SLE.
100
The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient’s knees?
a. Ulnar drift
b. Pain with joint movement
c. Reddened, swollen affected joints
d. Stiffness that increases with movement
b. Pain with joint movement
Rationale: Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.
100
A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern should the nurse recommend?
a. Bed rest with bathroom privileges
b. Daily high-impact aerobic exercise
c. Regular exercise program of walking
d. Frequent rest periods with minimal exercise
c. Regular exercise program of walking
Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.
200
The nurse is delivering teaching to a female patient newly diagnosed with systemic lupus erythematosus (SLE). Which statement demonstrates the patient’s need for further teaching about the disease?
a. “I’ll try my best to stay out of the sun this summer.”
b. “I know that I have a high chance of getting arthritis.”
c. “I’m hoping surgery will be an option for me in the future.”
d. “I understand I’m going to be vulnerable to getting infections.”
c. "I'm hoping surgery will be an option for me in the future."
Rationale: Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.
200
Which statement suggests a need for the nurse to assess the patient for ankylosing spondylitis?
a. “My right elbow has become red and swollen over the last few days.”
b. “I wake up stiff every morning, and my knees just don’t want to bend.”
c. “My husband tells me that my posture has become so stooped this winter.”
d. “My lower back pain seems to be getting worse and nothing seems to help.”
d. "My lower back pain seems to be getting worse and nothing seems to help."
Rationale: AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.
200
A 66-yr-old man with type 2 diabetes and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask?
a. “Did you have any hypoglycemic reactions?”
b. “Have you noticed any bruising or bleeding?”
c. “Have you had any dizzy spells when standing up?”
d. “Do you have any numbness or tingling in your feet?”
b. "Have you noticed any bruising or bleeding."
Rationale: Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both may increase the risk of bleeding. Patients with atrial fibrillation routinely take an anticoagulant to reduce the risk of venous thromboembolism and stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose, and hyperglycemia may occur.
200
A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan?
a. Joint destruction caused by an autoimmune process
b. Degeneration of articular cartilage in synovial joints
c. Overproduction of synovial fluid resulting in joint destruction
d. Breakdown of tissue in non–weight-bearing joints by enzymes
d. Breakdown of tissue in non-weight bearing joint by enzymes
Rationale: OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.
200
The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement?
a. “I perform range of motion exercises at least twice a day.”
b. “I use a heating pad for 20 minutes to reduce morning stiffness.”
c. “I take a 20-minute nap in the afternoon even if I sleep 9 hours at night.”
d. “I restrict fluids to prevent edema when taking methotrexate (Rheumatrex).”
d. "I restrict fluids to prevent edema when takin methotrexate (Rheumatrex)."
Rationale: Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.
300
Which nursing intervention is appropriate for a patient with Sjögren’s syndrome?
a. Ambulate with assistive devices.
b. Use lubricating eyedrops frequently.
c. Administer acetaminophen as needed.
d. Apply ice or heat compresses to affected areas
b. Use lubricating eyedrops frequently
Rationale: Sjögren’s syndrome is an autoimmune disorder in which lymphocytes attack moisture-producing glands. Treatment is symptomatic, including adding moisture to eyes and increasing intake of fluids, especially with meals.
300
The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure should the nurse recommend to slow progression of the disease?
a. Use a wheelchair to avoid walking as much as possible.
b. Sit in chairs that cause the hips to be lower than the knees.
c. Eat a well-balanced diet to maintain a healthy body weight.
d. Use a walker for ambulation to relieve the pressure on the hips.
c. Eat a well-balanced diet to maintain a healthy body weight
Rationale: Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.
300
When reinforcing health teaching on managing osteoarthritis, which patient statement indicates additional instruction is needed?
a. “I can use a cane to relieve the pressure on my back and hip.”
b. “I should take the Naprosyn as prescribed to help control the pain.”
c. “I should try to stay standing all day to keep my joints from becoming stiff.”
d. “A warm shower in the morning will help relieve the stiffness I have when I get up.”
c. "I should try to stay standing all day to keep my joints from becoming stiff."
Rationale: Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.
300
A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate?
a. “Infertility can result from some medications used to control your disease.”
b. “Temporary remission of your signs and symptoms is common during pregnancy.”
c. “Autoantibodies transferred to the baby during pregnancy will cause heart defects.”
d. “The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth.”
a. "Infertility can result from medications used to control your disease."
Rationale: Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common after pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.
300
The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites?
a. The best therapy for the acute illness is IV antibiotics.
b. Check for an enlarging reddened area with a clear center.
c. Surveillance is necessary during the summer months only.
d. Antibiotics will prevent Lyme disease if taken for 10 days.
b. Check for an enlarging reddened area with a clear center.
Rationale: After a tick bite, the expanding “bull’s eye rash” is the most characteristic symptom that usually occurs in 3 to 30 days. Flu-like symptoms and migrating joint and muscle pain also may be present. Active lesions are treated with oral antibiotics for 2 to 3 weeks; doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. No vaccine is available.
400
A patient with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider?
a. Red, scaly patches are noted on the arms.
b. Crackles are auscultated in the lung bases.
c. Hemoglobin is 11.1g/dL, and hematocrit is 35%.
d. Patient has continued pain after first week of etanercept therapy
b. Crackles are auscultated in the lung bases
Rationale: Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for a change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve symptoms.
400
The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information requires a discussion with the health care provider about an urgent change in the treatment plan?
a. Knee crepitation is noted with normal knee range of motion.
b. Patient reports embarrassment about having Heberden’s nodes.
c. Patient’s knee pain while golfing has increased over the last year.
d. Laboratory results indicate blood urea nitrogen (BUN) is elevated
d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.
Rationale: Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will also be reported to the health care provider but is consistent with the patient’s diagnosis of osteoarthritis and will not require an immediate change in the patient’s treatment plan
400
Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)?
a. A 56-yr-old man who has a sedentary office job
b. A 38-yr-old man who plays on a summer softball team
c. A 56-yr-old woman who works on an automotive assembly line
d. A 38-yr-old woman who is newly diagnosed with diabetes mellitus
c. A 56-yr-old woman who works on an automotive assembly line
Rationale: OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a risk factor for OA. Sedentary work is not a risk factor for OA
400
A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding by the nurse is important to report to the health care provider?
a. The patient has painful hematuria.
b. Acne is noted on the patient’s face.
c. Fasting blood glucose is 112 mg/dL.
d. The patient has an increased appetite
a. The patient has painful hematuria
Rationale: Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection
400
Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)?
a. Rheumatoid factor is positive.
b. Fasting blood glucose is 90 mg/dL.
c. The white blood cell (WBC) count is 1500/µL.
d. The erythrocyte sedimentation rate is elevated
c. The white blood cell (WBC) count is 1500/µL.
Rationale: Bone marrow suppression is a possible side effect of methotrexate, and the patient’s low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose is normal.
500
A patient with longstanding Raynaud’s phenomenon currently reports red spots on the hands, forearms, palms, face, and lips. Which additional findings would the nurse expect? (Select all that apply.)
a. Calcinosis
b. Weight loss
c. Sclerodactyly
d. Difficulty swallowing
e. Weakened leg muscles
f. Skin thickening below the elbow and knee
a. Calcinosis
c. Sclerodactyly
d. Difficulty swallowing
f. Skin thickening below the elbow and knee
Rationale: This patient is at risk for scleroderma. The acronym CREST represents the manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud’s phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.:
500
A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments would be included in the plan of care? (Select all that apply.)
a. Massage therapy
b. Low-impact aerobic exercise
c. Relaxation strategy (biofeedback)
d. Antiseizure drug pregabalin (Lyrica)
e. Morphine sulfate extended-release tablets
f. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])
a. Massage therapy
b. low-impact aerobic exercise
c. Relaxation strategy (biofeedback)
d. antiseizure drug pregabalin (Lyrica)
f. Serotonin reuptake inhibitor (e.g. sertraline [Zoloft])
Rationale: Massage will improve blood flow and relaxation. Low-impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation using biofeedback may decrease the patient’s stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will preferably be prescribed a nonopioid pain medication, an antiseizure medication such as pregabalin to help with widespread pain, and a serotonin reuptake inhibitor for depression. Long-acting opioids such as morphine are avoided unless other medications do not relieve pain.
500
A nurse assesses a patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect? (Select all that apply.)
a. Presence of nodules
b. Consistent muscle strength
c. Localized disease symptoms
d. No destructive changes on x-ray
e. Subluxation of joints without fibrous ankyloses
f. Joint space narrowing and formation of osteophytes
a. presence of nodules
e. Subluxation of joints without fibrous ankyloses
Rationale: In stage III severe RA, extraarticular soft tissue lesions or nodules may be present along with subluxation without fibrous or bony ankylosis. Muscle strength is decreased because of extensive muscle atrophy. Manifestations are systemic rather than localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Joint space narrowing with osteophytes is consistent with osteoarthritis.
500
During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)?
a. Sleep disturbances
b. Multiple tender points
c. Cardiac palpitations and dizziness
d. Multijoint inflammation and swelling
e. Widespread bilateral, burning musculoskeletal pain
a. sleep disturbances
b. multiple tender points
e. widespread bilateral, burning musculoskeletal pain
Rationale: These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia
500
When reviewing the health record for a new patient with rheumatoid arthritis, the nurse reads that the patient has swan neck deformities. Which deformity will the nurse expect to observe when assessing the patient?
a. A
b. B
c. C
d. D
D. D
Rationale: Swan neck deformity involves distal interphalangeal joint hyperflexion and proximal interphalangeal joint hyperextension of the hands. The other deformities are also associated with rheumatoid arthritis: ulnar drift, boutonniere deformity, and hallux vagus