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Chapter 20: Care of Patients with Arthritis and Other Connective Tissue Diseases

Test Bank
MULTIPLE CHOICE
1. The nurse is teaching a community health class about health promotion techniques. Which

statement by a student indicates a strategy to help prevent the development of osteoarthritis?


I will keep my BMI under 24.
I will switch to low-tar cigarettes.
I will start jogging twice a week.
I will have a family tree done.

a.
b.
c.
d.

ANS: A

Obesity increases the stress on weight-bearing joints and contributes to the development of
degenerative joint disease. Smoking does not decrease risk for osteoarthritis. Jogging
increases the risk because of increased wear and tear on the joints. There is a genetic link to
osteoarthritis; creating a family tree might help the client discover if there is any familial link
but will not help prevent the disorder.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
2. The nurse is teaching a client who has osteoarthritis ways to slow progression of the disease.

Which statement indicates that the client understands the nurses instruction?
I will eat more vegetables and less meat.
I will avoid exercising to minimize wear on my joints.
I will take calcium with vitamin D every day.
I will start swimming twice a week.

a.
b.
c.
d.

ANS: D

Swimming is an excellent form of exercise for clients with arthritis because it involves
minimal weight bearing and stress on the joints from gravity. Eating more vegetables will not
decrease the progression of osteoarthritis. Taking calcium with vitamin D will decrease the
risk of osteoporosis, not osteoarthritis. Gentle exercise is important to help slow progression
of the disease.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
3. The nurse is working with a client who will be taking 20 mg of prednisone daily for

rheumatoid arthritis. Which precautions does the nurse give the client about taking this
medication?
a. Take this medication at bedtime because it will make you sleepy.
b. Take calcium and vitamin D supplements daily.
c. Eat a high-fiber diet with lots of lean meats.
d. Wash your face twice a day with an antibacterial soap.
ANS: B

Long-term steroid use is associated with many complications, including diabetes, infection,
and osteoporosis, among others. The client should be instructed to take calcium and vitamin D
supplements to help prevent osteoporosis. Prednisone does not cause constipation, so
increased fiber would not be helpful. Prednisone should be taken in the morning because it
may interfere with sleep if taken at bedtime. Washing the face with antibacterial soap may
cause skin dryness and breakdown.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
4. An older adult client is scheduled for knee replacement surgery. Which statement by the client

indicates a need for further preoperative instruction?


a. I need to keep my leg positioned away from my body.
b. I may have a continuous passive motion machine for a few days.
c. I may need more pain medicine than I did with my hip replacement.
d. I probably can get back to work within 2 to 3 weeks.
ANS: A

Dislocation is not a problem with knee replacement surgery, so the client does not need to
keep his or her leg abducted. The other statements indicate accurate understanding of the
instructions.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Evaluation)
5. A client returns to the medical-surgical unit after a total hip replacement with a large wedge-

shaped pillow between his legs. The clients daughter asks the nurse why the pillow is in
place. What is the nurses best response?
a. It will help prevent bedsores from developing.
b. It will help prevent nerve damage and foot drop.
c. It will keep the new hip from becoming dislocated.
d. It will prevent climbing out of bed if he becomes confused.
ANS: C

Adduction of the operative leg beyond the midline could dislocate the new hip. The wedge
pillow will help prevent this from happening. The wedge will not prevent bedsores from
developing because it does not prevent pressure. The pillow will not prevent foot drop,
because it is placed between the legs. The pillow is not a restraining device, and it will not
prevent the client from climbing out of bed.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 325
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Communication and Documentation
6. The nurse is caring for a postoperative client on the medical-surgical unit following a total left

hip replacement the previous day. During the assessment, the nurse notes that the clients left
leg is cool, with weak pedal pulses. What is the nurses first action?

a.
b.
c.
d.

Assess circulatory status of the right leg.


Notify the surgeon immediately.
Measure leg circumference at the calf.
Check for bilateral Homans signs.

ANS: A

The symptoms may represent impaired circulation or may be normal for this client. Before the
surgeon is notified, the status of the nonoperative leg should be assessed and assessment
findings on both legs compared with the clients baseline. Homans sign (pain in the calf on
dorsiflexion of the foot) is not always indicative of a deep vein thrombosis and should not be
evaluated until other assessments are made. Measuring calf circumference would provide
additional data related to deep vein thrombosis.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
7. A client is admitted for a total hip replacement. Past medical history includes diabetes mellitus

type 2, a heart attack 5 years ago, and allergies to sulfa drugs. The client currently takes
insulin on a sliding scale and celecoxib (Celebrex). Before administering the clients
medications, which action by the nurse is most appropriate?
a. Take the clients blood pressure in both arms.
b. Call the physician to clarify the orders.
c. Schedule a preoperative electrocardiogram.
d. Review the clients laboratory values.
ANS: B

Celebrex is a cyclooxygenase (COX)-2 inhibitor. These drugs are thought to cause serious
adverse reactions such as myocardial infarction and renal problems. This client already has
coronary artery disease and a past myocardial infarction, so the nurse should discuss the order
with the physician before giving the medication. Reviewing laboratory results could indicate
renal impairment, but taking the clients blood pressure and scheduling an electrocardiogram
(ECG) would not take priority over discussion with the physician.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
8. A client is receiving warfarin (Coumadin) daily following total hip replacement surgery.

Which laboratory value requires intervention by the nurse?


Potassium (K+), 4.2 mEq/L
International normalized ratio (INR), 5.1
Prothrombin time (PT), 13.4 seconds
Hemoglobin (Hg), 16 g/dL

a.
b.
c.
d.

ANS: B

Blood levels of Coumadin will be monitored by checking daily PT and INR (in some places,
only INR). The INR is critically high. The K+ is normal and is not monitored for Coumadin
therapy. The PT is used in some facilities to monitor Coumadin therapy. Hemoglobin would
be important to assess because a side effect of Coumadin is bleeding, and a dropping
hemoglobin level would indicate that bleeding was occurring. PT and hemoglobin are within
the normal range.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory
Values)
MSC: Integrated Process: Nursing Process (Assessment)
9. The nurse is caring for a client who is 1 day post total hip replacement. The nurse is

instructing the client about how to perform quadriceps-setting exercises correctly. Which
direction does the nurse provide to the client?
a. Straighten your legs and push the back of your knees into the mattress.
b. Straighten your legs and bring each leg separately off the mattress 6 inches.
c. Raise each leg 10 inches off the bed, keep it straight, and make ankle circles.
d. Bend each knee, and rapidly point your toes downward and then upward.
ANS: A

Quadriceps-setting exercises are done by straightening the leg as much as possible by


attempting to push the back of the knees into the mattress. The other exercises may be
performed by the client as tolerated, but these items do not describe quadriceps-setting
exercises.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 327
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Teaching/Learning
10. The home care nurse is making a follow-up visit to a client who had total hip replacement

surgery 2 weeks ago. Which client statement indicates a need for clarification regarding
postoperative routine?
a. My daughter helps me put on my elastic TED (thromboembolic deterrent) hose
every day.
b. I take 200 mg of Motrin (ibuprofen) at bedtime so that I can sleep.
c. Now that my hip doesnt hurt, I can cross my legs like a lady again.
d. Each day, I try to increase my walking time by at least 10 minutes.
ANS: C

Crossing the legs beyond midline can dislocate the new hip joint and should be avoided at all
times. The other statements demonstrate correct behavior and understanding.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
11. A client who has had bilateral total knee replacements is prescribed enoxaparin sodium

(Lovenox) injections twice daily for the next 3 weeks. The client asks the nurse why she has
to have the medication. What is the nurses best response?
a. To prevent swelling within your new knee joints.

b. To prevent the formation of blood clots in your legs.


c. To prevent arthritis from developing in your new knee joints.
d. To prevent an infection from developing in your new knee joints.
ANS: B

Lovenox is an anticoagulant that will help prevent formation of postoperative deep vein
thrombosis (DVT). Lovenox does not decrease or prevent swelling, it does not prevent
arthritis, and it is not an antibiotic.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 327
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Expected Actions/Outcomes) MSC:
Integrated Process: Teaching/Learning
12. The nurse is caring for a client who had right total knee replacement surgery 3 days ago.

During the assessment, the nurse notes that the clients right lower leg is twice the size of the
left. What is the nurses priority intervention?
a. Elevate the clients right leg.
b. Apply antiembolism stockings.
c. Assess the clients respiratory status.
d. Check the clients pedal pulses.
ANS: C

A common complication after total knee replacement (TKR) is the formation of a thrombus
below the surgical site. This complication can lead to a pulmonary embolus and can be life
threatening. Before notifying the surgeon or the emergency team, assess the clients
pulmonary status to determine whether he or she has any manifestations of an embolus. The
clients leg may be elevated and pedal pulses palpated, but respiratory assessment must be
done first. TED hose should not be applied to a leg with suspected deep vein thrombosis
(DVT).
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
13. A client had a total knee replacement earlier in the day and has a continuous femoral nerve

blockade (CFNB). When entering the room to assess the client, the nurse notes that the
television volume is quite loud. The client explains that it is hard to hear with all the ringing
in my ears. What action by the nurse takes priority?
a. Perform a neurovascular assessment on the operative extremity.
b. Call another nurse to notify the anesthesiologist immediately.
c. Take a full set of vital signs and discontinue the CFNB.
d. Pad the siderails and instituting other seizure precautions.
ANS: B

CFNB can enter the systemic circulation, causing tinnitus, nervousness, slurred speech,
bradycardia, hypotension, bradypnea, and seizures. Because the client is exhibiting signs the
CFNB has entered his or her circulation, the client is at risk for seizures and critical alterations
in vital signs. The nurse should stay with the client and should continue to assess him or her
while another nurse notifies the surgeon or the anesthesiologist.
DIF: Cognitive Level: Application/Applying or higher

REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
14. A client who has had total hip replacement surgery asks the nurse when she will be able to use

a regular-height toilet seat again. What is the nurses best response?


a. As soon as you are able to walk without a limp.
b. As soon as the staples are removed from the incision.
c. When you are off pain medication and warfarin (Coumadin).
d. When you can hold your leg 6 inches off the bed for 5 full minutes.
ANS: A

When the client is able to walk without a limp, the artificial joint is seated sturdily enough in
place that it will not be dislocated or dislodged by overflexing it. At that time, the client will
no longer need assistive devices or ambulatory aids. With staples removed, holding the leg off
the bed and taking Coumadin do not affect readiness to bend the hip enough to use a regular
toilet seat.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 328
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
15. The nurse is caring for a client who has had hip replacement surgery 2 days before. The client

reports severe pain at the surgical site despite having received 2 Vicodin (acetaminophen and
hydrocodone) tablets 2 hours previously. The client is requesting IV pain medication. What is
the nurses primary intervention?
a. Assess the surgical site for signs of infection.
b. Administer 2 more Vicodin tablets.
c. Apply a large ice bag to the operative site.
d. Reassure the client that the Vicodin will work soon.
ANS: A

Most clients do not need IV pain medication after the first day. If the client seems to be having
unusual pain, the nurse should first assess the client for other problems, such as a joint
infection. If findings are normal, applying ice to the hip will help to reduce swelling and pain.
It is not time for another dose of Vicodin, because it has only been 2 hours. The nurse would
not contact the surgeon unless all pain methods tried did not work. The Vicodin should have
worked within 2 hours, so the nurse should not tell the client that the Vicodin will work
shortly.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNonPharmacological Comfort Interventions)
MSC: Integrated Process: Nursing Process (Implementation)
16. A client is suspected to have rheumatoid arthritis. Which manifestations does the nurse assess

this client carefully for?


a. Crepitus when the client moves the shoulders
b. Numbness and tingling in the clients fingers
c. Client has cool feet, with weak pedal pulses
d. Low-grade fever, fatigue, anorexia with weight loss

ANS: D

Low-grade fever is common with rheumatoid arthritis because of the inflammatory response.
Fatigue, anorexia, and weight loss are also common symptoms. Impaired neurologic status,
popping sounds with range of motion (ROM), and poor circulation are not common symptoms
of rheumatoid arthritis.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
17. The nurse is teaching a client how to reduce the pain that she often experiences with

fibromyalgia. Which statement does the nurse include in the teaching?


Wear gloves outdoors in cooler temperatures.
Avoid exercising when your muscles are sore.
Make sure that you get enough sleep every night.
Stay out of the sun as much as possible.

a.
b.
c.
d.

ANS: C

In many clients, the pain of fibromyalgia occurs as a direct response to sleep deprivation.
Encouraging the client to get sufficient sleep every night can drastically reduce the amount of
pain experienced. Wearing gloves will not decrease the pain of fibromyalgia, but it may help a
disease such as Raynauds phenomenon. Weight-bearing activities should not increase pain in
a client with fibromyalgia. Similarly, sun exposure has not been identified as a causative pain
factor.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNonPharmacological Comfort Interventions)
MSC: Integrated Process: Teaching/Learning
18. A client with a history of rheumatoid arthritis will be starting drug therapy with etanercept

(Enbrel). What is most important for the nurse to teach the client?
The correct technique for subcutaneous injections
How to self-monitor blood glucose levels
How to set up and prime the IV tubing
How to calculate the dosage based on symptoms

a.
b.
c.
d.

ANS: A

Enbrel is a parenteral medication that is given by subcutaneous injection. The client and/or the
family will need to be taught how to give a subcutaneous injection correctly. Blood glucose
levels should not be affected by this medication. The medication is not administered IV. Drug
dosages are not changed and recalculated by the client.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
19. The nurse provides discharge teaching for a client to prevent a new attack of gout. Which

statement by the client indicates that additional teaching is required?


a. I will keep a food and symptom diary for a few weeks.
b. If I get a headache, I will take Tylenol instead of aspirin.

c. I hate to start limiting my fluid intake so much!


d. Citrus juices and milk may keep me from having kidney stones.
ANS: C

Nutritional therapy for gout is controversial; however, clients do need to increase their fluid
intake to prevent kidney stones. Certain foods may precipitate an acute attack, so clients
should learn to determine which foods trigger their gout. Aspirin is well known to trigger gout
attacks. Increasing the intake of alkaline ash foods such as citrus juices and milk might
prevent the formation of kidney stones.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
20. The school nurse is working with a group of high school students who will be going on a field

trip to a nature center. Which student is at highest risk for a tick bite?
Male student with a beard and a baseball cap
Female student with long hair pulled back in a ponytail
Male student wearing a long-sleeved shirt and shorts
Female student who is wearing scented hand lotion

a.
b.
c.
d.

ANS: C

Long pants should be worn and tucked into socks or boots to help prevent tick bites. Facial
hair, hats, ponytails, and scented body products do not increase the risk for tick bites.
DIF: Cognitive Level: Comprehension/Understanding
REF: Chart 20-15, p. 353
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
21. The school nurse removes a tick embedded in a students scalp by the hairline. Which follow-

up instruction is the nurse sure to provide to the mother?


Call your pediatrician right away if a fever or a red rash develops at the bite.
If your child does not have symptoms within 2 weeks, you can relax.
Call your pediatrician tomorrow to get antibiotics to prevent Lyme disease.
Keep the site clean, but you dont have to worry about further problems.

a.
b.
c.
d.

ANS: A

The mother should be instructed to monitor for early symptoms of Lyme disease (fever, rash
at the site, other flulike symptoms) following a tick bite. Symptoms can appear for up to 30
days after the bite. Antibiotics are not prescribed as a preventive measure. Because Lyme
disease can cause serious complications, the mother needs to monitor the childs condition
carefully.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems)
MSC: Integrated Process: Teaching/Learning
22. The nurse has taught a client with lupus about skin protection in the clinic. Later, the nurse

sees the client at an outdoor music festival. Which observation by the nurse indicates that the
client requires further instruction?
a. Client is wearing a thin, long-sleeved shirt.
b. Client is wearing a hat with a full brim.

c. Client is discussing her new perm.


d. Client is seen applying sunscreen twice.
ANS: C

Alopecia is common; the client should use gentle shampoo and avoid any harsh chemical
treatments, such as a permanent wave. The other observations show good skin protection
practices by the client.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 346
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Assessment)
23. A client with diagnosed osteoarthritis comes to the clinic reporting a low-grade fever, fatigue,

and bilateral joint pain. What action by the nurse is most appropriate?
Assess the client for a systemic infection.
Discuss increasing the dose of anti-arthritis drugs.
Prepare the client for a laboratory draw for rheumatoid factor.
Teach the client joint protection activities.

a.
b.
c.
d.

ANS: C

Osteoarthritis is generally a unilateral disease. The manifestations that this client exhibits are
more consistent with rheumatoid arthritis, so the nurse will prepare the client for a blood draw.
The nurse may need to teach joint protection measures, but an accurate diagnosis is most
important.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
24. The nurse is working in a primary care clinic and sees a young male client. The client is

athletic and is well over 6 feet tall, with size 14 shoes. What diagnostic test does the nurse
facilitate for the client?
a. Coagulation studies
b. Echocardiography
c. Electromyelography
d. Genetic testing
ANS: B

Marfan syndrome is seen in athletic clients who are very tall and have large hands and feet.
Echocardiography should be done for clients who may have Marfan syndrome to monitor for
mitral valve prolapse and aortic aneurysm. Marfan disease has a genetic component, and
genetic testing may be done, but the priority is monitoring the client for cardiac
complications.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
25. The nurse is working in a clinic when a young male client presents with reports of pain with

urination. The client wants testing for sexually transmitted diseases (STDs). The nurse notes
that the clients eyes are red and inflamed. What question by the nurse is most important?

a.
b.
c.
d.

Do you have more than one sexual partner?


Do you have any new joint pain?
What eyedrops have you used for your red eyes?
Are you allergic to any antibiotics?

ANS: B

The client has two symptoms of Reiters syndrome (urethritis and conjunctivitis). The nurse
should ask about joint pain because this is the third classic manifestation of this disease. All
other questions are appropriate, but before treatment is started, the client needs an accurate
diagnosis.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological IntegrityPathophysiology)
MSC: Integrated Process: Nursing Process (Planning)
26. A client presents with painful, inflamed fingers with small, hard, yellow nodules that have a

sandy yellow drainage. Which medication does the nurse prepare to administer to the client?
a. Colchicine (Colasalide)
b. Allopurinol (Zyloprim)
c. Methotrexate (Rheumatrex)
d. Aspirin
ANS: B

The client is presenting with symptoms of chronic gout, and allopurinol would be the drug of
choice to reduce uric acid levels. Colchicine is used to treat acute gout attacks. Methotrexate
and aspirin are not used to treat chronic gout.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Expected Actions/Outcomes) MSC:
Integrated Process: Nursing Process (Planning)
27. A client had a total knee replacement this morning and has a continuous passive motion

(CPM) machine. What activity related to the CPM does the RN delegate to the unlicensed
assistive personnel?
a. Placing controls out of the reach of confused clients
b. Assessing the clients response to the CPM
c. Teaching the clients family the rationale for the CPM
d. Assessing neurovascular status of the leg in the CPM
ANS: A

All activities are appropriate for the client with a CPM, but the nurse can delegate only the
task of keeping controls out of reach of the confused client. All other activities would need to
be performed by the RN.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Delegation)
MSC: Integrated Process: Communication and Documentation
28. A client with chronic gout takes probenecid (Benemid) and comes to the clinic reporting

frequent severe headaches and a new gout flare. The client is frustrated because the gout had
been under good control. Which question by the nurse is most helpful?
a. What do you take for your headaches?

b. Do you know what triggers your gout?


c. Have you been following your diet?
d. Did you switch from wine to beer lately?
ANS: A

The nurse needs to assess what has changed for this client. The new onset of headaches should
prompt the nurse to question the client about pain medications because aspirin inactivates
probenecid. Gout can have triggers, but the client probably knows them by now if it has been
well controlled. Nutritional therapy for gout remains controversial. Excessive alcohol can
trigger an episode, but beer does not contribute any more than wine.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Assessment)
29. The nurse is caring for a pregnant client who is taking Humira (adalimumab) to control

symptoms of rheumatoid arthritis. The client mentions the pain and inconvenience of the
subcutaneous injections and asks, While Im pregnant, can I take this drug by mouth
instead? What is the nurses best response?
a. I will ask the physician to write a prescription for you today.
b. Humira takes much longer to work when it is given orally.
c. Humira can be given only by subcutaneous injection.
d. You can switch from Humira to oral leflunomide (Arava).
ANS: C

Humira is given by subcutaneous injection only. Arava causes birth defects; clients taking it
must be on strict birth control and must inform their health care providers if pregnancy occurs.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Expected Actions/Outcomes) MSC:
Integrated Process: Teaching/Learning
30. A female client with rheumatoid arthritis has taken Rheumatrex (methotrexate) for the past

year to control her symptoms. The client comes to the clinic and tells the nurse that a home
pregnancy test was positive. What is the nurses best response?
a. You need to schedule a prenatal appointment with your obstetrician right away.
b. Stop taking Rheumatrex immediately. Ill tell the physician you are pregnant.
c. Continue taking the Rheumatrex, and increase the dose if you have a flare.
d. See a genetic counselor to determine whether your baby will have rheumatoid
arthritis.
ANS: B

Rheumatrex is highly teratogenic and should not be taken during pregnancy. A prenatal
appointment should be made right away, but the first priority is to stop taking methotrexate.
Genetic counseling is not appropriate because the counselor will not be able to determine
whether the baby will develop rheumatoid arthritis.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)

31. The nurse is instructing a client about management of discoid lupus erythematosus (DLE).

Which statement indicates that the client requires additional teaching?


I will be sure to apply sunscreen whenever I am outside.
I will apply small amounts of the steroid cream to my face twice a day.
I will take Plaquenil (hydroxychloroquine sulfate) with breakfast each morning.
Steroids weaken the immune system, so I will wash my hands frequently.

a.
b.
c.
d.

ANS: D

Steroid creams used for the treatment of discoid lupus will not weaken the immune system
because they should be applied in small amounts to affected areas. The client will be more
sensitive to sun exposure while using the steroid cream, so sunscreen should be used
whenever the client goes outside. The client should use only small amounts of the cream on
her face. Plaquenil should be taken with meals or a glass of milk.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Expected Actions/Outcomes) MSC:
Integrated Process: Teaching/Learning
32. Which statement by a client indicates that additional teaching is needed in the management of

fibromyalgia?
I will switch to decaffeinated coffee in the mornings.
Water aerobics classes will be a good form of exercise.
Limiting my physical activity will reduce my fatigue.
I will take my sertraline (Zoloft) right before I go to bed.

a.
b.
c.
d.

ANS: C

Clients with fibromyalgia should be encouraged to exercise regularly, particularly performing


activities that are low impact. Sleep disturbances are common in fibromyalgia, and anything
that interferes with sleep, such as caffeine, should be avoided. Zoloft can cause drowsiness
and should be taken daily at bedtime.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
33. The nurse is caring for a client who has dysphagia caused by systemic sclerosis. What is the

best intervention for the nurse to implement for this client?


a. Encourage frequent, high-protein, easy to swallow foods.
b. Teach the client to lie flat after meals to prevent reflux.
c. Thicken liquids to a nectar or honey consistency.
d. Have the client hyperextend his or her neck while swallowing.
ANS: A

Clients with dysphagia frequently have esophageal motility problems, and swallowing
becomes difficult. This, combined with malabsorption, leads to a malnourished client.
Frequent small meals consisting of high-protein and easy to swallow foods are best. Clients
should eat only in an upright position to reduce choking. Thickening liquids may help, but this
does not address the malnutrition. Hyperextending the neck may help, but specific techniques
should be determined by a swallowing study.
DIF: Cognitive Level: Application/Applying or higher

REF: N/A

TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNutrition and Oral
Hydration)
MSC: Integrated Process: Nursing Process (Implementation)
34. The nurse is instructing a client about the management of systemic sclerosis. Which statement

indicates that the client requires additional teaching?


I will let my doctor know right away if I develop a fever.
Ice packs will help relieve the aching pain in my hips and knees.
I will wear mittens when I am in the freezer section of the grocery store.
I will apply a rich moisturizer to my skin every morning after my shower.

a.
b.
c.
d.

ANS: B

Ice packs should not be used by clients with systemic sclerosis because the cold can trigger
symptoms of Raynauds phenomenon. The client should wear mittens whenever his or her
hands are exposed to cold temperatures, and moisturizer should be applied daily. The client
should notify the doctor if a fever develops.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
35. The nurse is working at a clinic, where several clients are waiting to be seen. Which client

does the nurse assess first?


Client with temporal arteritis with new onset of blurry double vision
Client with polymyalgia rheumatica with low-grade fever and fatigue
Client with polymyositis reporting generalized rash and joint pain
Client with ankylosing spondylitis who presents with back pain and weight loss

a.
b.
c.
d.

ANS: A

Vision changes in a client with temporal arteritis are a dangerous sign that warrants immediate
medical attention. The other clients signs and symptoms are commonly seen with their
conditions and may be addressed on a more routine basis.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
36. The nurse is caring for a female client who has a history of chronic fatigue syndrome. Which

finding is the nurse surprised to see in the clients record?


Hemoglobin, 7.2 g/dL
Serum creatinine, 0.9 mg/dL
Multiple tender lymph nodes
Newly red, swollen, warm knee

a.
b.
c.
d.

ANS: A

Laboratory values are typically normal for chronic fatigue syndrome, and no laboratory test
can confirm the disease. A hemoglobin level of 7.2 is very low and is not seen with chronic
fatigue syndrome. The creatinine value is normal. Tender lymph nodes and inflamed joints are
normal findings in chronic fatigue syndrome.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)

37. A client with rheumatoid arthritis had abdominal surgery and has returned to the postoperative

nursing unit. The client is unable to use the incentive spirometer correctly, demonstrating
limited lung volume and fatiguing easily. What action by the nurse takes priority?
a. Notify the physician immediately.
b. Have respiratory therapy re-instruct the client.
c. Assess for pain and medicate if necessary.
d. Let the client rest for a few hours.
ANS: A

Clients with rheumatoid arthritis can have cervical spine involvement resulting in subluxation.
This may lead to decreased respiratory function and can be life threatening. This client was
recently intubated for an operation and so is at higher risk for this problem. The nurse should
notify the physician immediately and continue assessing the client.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
38. A nurse is caring for a client who has had rheumatoid arthritis (RA) for 5 years. Which

laboratory value requires the most immediate intervention by the nurse?


White blood cell count (WBC), 3800/mm3
Hemoglobin (Hg), 10.6 g/dL
Blood urea nitrogen (BUN), 16 mg/dL
Creatinine, 3.2 mg/dL

a.
b.
c.
d.

ANS: D

Clients with RA usually have pancytopenia, or a decrease in all cell types. WBC and
hemoglobin are low, consistent with this condition. BUN is normal. Creatinine is very high;
this indicates renal disease. This client may have renal consequences of his or her RA, which
should be investigated.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory
Values)
MSC: Integrated Process: Nursing Process (Analysis)
39. The nurse is caring for an older adult client who will be discharged after being hospitalized for

a total hip replacement. Which statement indicates that arrangements may have to be made to
have the clients medications supervised at home?
a. I will take my Coumadin pill every day just before the evening news.
b. My wife takes iron too, so we will take our pills together every morning.
c. I prepare all my pills for the week and will place them in a labeled medi-set.
d. If my legs get swollen, I will take an extra Coumadin pill that day.
ANS: D

Warfarin (Coumadin) is an anticoagulant prescribed to prevent venous thromboembolism after


joint replacement surgery. It is not used for edema. The other statements show that the client
has an appropriate plan for self-administration of his medications.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Assessment)


40. The nurse is working with a client who has severe rheumatoid arthritis in her hands. The client

states that she is frustrated at mealtime because it is difficult for her to manage cups and
silverware. What is the nurses best response?
a. Ill have the nursing assistants set up your meal trays while you are in the
hospital.
b. Lets see if the occupational therapist can provide you with some utensils that are
easier for you to use.
c. Ill arrange for a home nursing assistant to help you with your meals after you are
discharged from the hospital.
d. Lets see if the physical therapist can suggest some muscle strengthening exercises
for you.
ANS: B

The client wishes to be more independent at mealtimes; adaptive eating utensils from the
occupational therapist will help her meet this goal. Muscle-strengthening exercises will not be
as effective for the clients mealtime needs. The client wishes to remain as independent as
possible, so a home nursing assistant should not be suggested.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Collaboration with Interdisciplinary Team)
MSC:
Integrated Process: Caring
41. The nurse is caring for an older adult client who will be discharged home to live with an adult

daughter. The client will be given prescriptions for four new medications for rheumatoid
arthritis. How does the nurse ensure that the client will be able to take the medications
correctly at home?
a. Monitor the client self-administering medications while in the hospital.
b. Include the clients daughter when teaching the client about the medications.
c. Provide the client with pamphlets and information about all the medications.
d. Make a chart showing which medications the client should take at different times.
ANS: B

Because the client will be living with the daughter, she should be included in the teaching plan
about the medications. Providing pamphlets or charts about the medications does not ensure
that the client knows how to take them correctly at home. Self-administering medications may
or may not be permitted by hospital policy and might be helpful, but including the daughter
would be the best option.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Assessment)
42. The nurse is caring for an older adult client who has fallen and fractured her hip. The client

will have hip replacement surgery followed by extensive rehabilitation. The client confides in
the nurse, I feel like I dont have any control over anything anymore now that I am old.
What is the nurses best response?
a. Ill make sure that the physical and occupational therapists see you after surgery to
help get your strength back.
b. Its normal to feel this way, but hopefully you will be back on your feet after a

stay in rehab.
c. Its important to control what you can right now, like making out your menu every
day and working with the therapists.
d. I sense that you are feeling depressed about the situation. I will ask the doctor to
prescribe an antidepressant for you.
ANS: C

The nurse should support the clients self-esteem and increase feelings of competency by
encouraging activities that assist in maintaining some degree of control, such as participation
in decision making and performance of tasks that he or she can manage. The nurse should
provide immediate control options for the client, rather than waiting until after rehabilitation.
The clients desire for control does not indicate depression, so an antidepressant is not
indicated. Therapy referrals are appropriate but do not address the clients desire for control.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Caring
43. The nurse is caring for an older adult client who has had a hip replacement 2 days previously.

Which assessment finding is the best indicator that the client does not need pain medication at
this time?
a. The client received 2 pain pills 2 hours ago.
b. The client states that she has no pain.
c. The client is sleeping quietly.
d. The clients vital signs are stable.
ANS: B

The clients report of pain is the best indicator of pain level, rather than vital signs, sleeping,
or time of last pain medication.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Assessment)
44. The nurse is caring for a client who has a history of severe rheumatoid arthritis. The client

becomes combative and abusive to the staff when she is unable to perform personal care
independently. What is the best statement the nurse can make to the client at this time?
a. I will have to restrain your hands if you cannot keep them to yourself.
b. I will ask your doctor for a psychiatrist to talk to you about anger management.
c. You seem frustrated. Would you like to try to dress again in a few minutes?
d. Would you like me to get an order for medication to help you settle down?
ANS: C

The client is acting out her frustration over her chronic illness and loss of use of her hands.
The nurse should acknowledge this frustration. Allowing the client to make decisions
regarding care will help the client regain some sense of control and will help improve selfesteem. Requesting sedation, suggesting psychiatric therapy, or threatening use of restraints is
not appropriate, because the client is expressing frustration over the situation.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Caring


MULTIPLE RESPONSE
1. What interventions does the nurse recommend for a client who is to be discharged home

following total hip replacement surgery? (Select all that apply.)


a. Continuous passive motion machine
b. Elevated toilet seat
c. Walker
d. Crutches
e. TED hose
f. Heating pad
ANS: B, C, E

The client will be using a walker, because crutches are used only by younger clients. TED
hose should be worn until the client regains full mobility and Coumadin is discontinued. A
walker will be needed until the client regains full strength and is able to walk with full weight
bearing on the operative side. Crutches are not used because they do not provide enough
support for the client during ambulation and pose a risk for falls. Heating pads increase blood
flow to the area and may increase pain. Ice packs should be used instead, as needed.
Continuous passive motion machines are not used after hip surgery.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
2. After hip replacement surgery, a client receives two doses of enoxaparin (Lovenox) during the

day shift. What orders does the nurse anticipate for the client? (Select all that apply.)
Laboratory draw for platelet count
Laboratory draw for prothrombin time (PTT)
Laboratory draw for international normalized ratio (INR)
Order for protamine sulfate
Order for vitamin K

a.
b.
c.
d.
e.

ANS: A, D

Lovenox is a lowmolecular-weight heparin. Side effects can include thrombocytopenia. The


antidote for all heparin products is protamine sulfate, although it will not be as effective for
Lovenox as it is for unfractionated heparin.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Analysis)
3. The nurse is teaching a client with rheumatoid arthritis (RA) about joint protection principles.

What information does the nurse include? (Select all that apply.)
Use smaller joints to rest the larger ones.
Hold objects with two hands, not one.
Sit most often in a reclining chair.
Use assistive-adaptive devices.
Bend at your knees to lift objects.

a.
b.
c.
d.
e.

ANS: B, D, E

Clients with RA should use large joints to protect smaller ones, should hold objects with two
hands instead of one, should sit in chairs with straight backs, should not bend at the waist but
rather bend the knees while keeping the back straight, and should use assistive-adaptive
devices wherever possible.
DIF: Cognitive Level: Comprehension/Understanding
REF: Chart 20-6, p. 332
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning