Unit 6: Ch 50 (Porth's 5th Ed) - Disorders of Musculoskeletal Function: Rheumatic Disorders Flashcards
- A 68-year-old woman has had her mobility and quality of life severely affected by
rheumatoid arthritis (RA). Place the following pathophysiological events involved in her
health problem in the correct order that they most likely occurred. Use all the options.
A) Inflammatory response
B) Interaction between rheumatoid factor (RF) and IgG
C) T-cell–mediated immune response
D) Pannus invasion
E) Destruction of articular cartilage
Ans: C, B, A, D, E
Feedback:
RA is thought to begin with a T-cell–mediated immune response that precipitates
interaction between IgG and RF that constitutes an immune response. Pannus invasion
is one consequence of this interaction, the ultimate result of which is destruction of
cartilage.
- Following a progressive onset of fatigue, aching, and joint stiffness over the last 2 years,
a 69-year-old male has recently been diagnosed with rheumatoid arthritis (RA). Which
of the following teaching points should his primary care physician include during the
office visit in which this diagnosis is communicated to the client?
A) “The symptoms you’ve been experiencing are the result of damage inside your
joints, but I’ll start you medications that will reverse this damage.”
B) “It’s important that you maximize your level of activity, since decreasing your
mobility will worsen the disease.
C) “The best treatment plan is to try all other available treatments before resorting to
using medications.”
D) “Steroids and anti-inflammatory drugs that I’ll prescribe will likely bring some
relief to your symptoms.”
Ans: D
Feedback:
Current treatment guidelines for RA involve early and aggressive pharmacological
treatment, including NSAIDs and corticosteroids. Damage cannot be reversed, and
while therapeutic exercise plays a role in treatment, rest is also important
- The physician is considering prescribing an anti-tumor necrosis factor (TNF) like
infliximab for a rheumatoid arthritis patient. Which of the following statements is
accurate about the advantages of using a TNF inhibitor?
A) “Since TNF inhibitors have few side effects, these drugs will fit well into your
regimen.”
B) “Your disease-modifying antirheumatic drug (DMARD) methotrexate has more
cardiovascular side effects than TNF inhibitors.”
C) “TNF inhibitors help slow the disease progression and improve your ability to
perform routine ADL functions.”
D) “Not only do TNF inhibitors control your disease better but they also will
interrupt the inflammatory cascade at several levels.”
Ans: C
Feedback:
Second-line antirheumatic drugs include anti-TNF drugs such as etanercept, infliximab,
and adalimumab. These drugs are biologic response–modifying agents or TNF
inhibitors that block TNF-a, one of the key proinflammatory cytokines in RA.
Anti-TNF-a agents have shown significant efficacy although they do have some
potential adverse side effects. Evidence indicates that CV side effects are not different
for TNF inhibitors than for DMARDs. The TNF inhibitor agents also have been shown
to inhibit radiologic disease progression and improve functional outcomes.
- A physician is attempting a differential diagnosis of a 30-year-old female who is
suspected of having systemic lupus erythematosus (SLE). Which of the following
aspects of the physician’s assessment and the client’s history would be considered
potentially indicative of SLE? Select all that apply.
A) The client has a “butterfly rash” on her nose and cheeks.
B) She complains of intermittent joint pain.
C) The woman states that she has numerous environmental allergies.
D) The client has been hospitalized twice in the past for pleural effusions.
E) Blood work indicates low red cells, white cells, and platelets.
Ans: A, B, D, E
Feedback:
A butterfly rash, joint pain, pleural effusion, and low levels of blood cellular
components are all associated with SLE. Environmental allergies are not noted to be risk
factors or associated symptoms of the disease.
- A new patient arrives at the clinic. The physician is suspecting that the patient may have
systemic lupus erythematosus (SLE) given the clinical manifestations related to joint
pain, skin changes, and a history of pleural effusions. The nurse should anticipate which
of the following diagnostic test will be a priority to facilitate with the diagnosis?
A) Anti-DNA antibody test
B) Routine hemoglobin
C) C-reactive protein
D) B-cell lymphocytes
Ans: A
Feedback:
Ninety-five percent of people with untreated SLE have high ANA levels. However,
ANA is not specific for SLE. The anti-DNA antibody test is more specific for the
diagnosis of SLE. Hemoglobin may be low if the patient has severe anemia, but it is not
specific for SLE. C-reactive protein will show an inflammatory response but again not
specific for SLE.
- A 44-year-old woman who has a long-standing diagnosis of SLE has been able to
control her symptoms with lifestyle modifications for several years, but has presented to
her care provider due to recent exacerbation. Which of the following pharmacological
treatment options is her care provider most likely to rule out first?
A) Nonsteroidal anti-inflammatory drugs
B) Corticosteroids
C) Antiplatelet aggregator
D) Immunosuppressive drugs
Ans: C
Feedback:
While NSAIDs, corticosteroids, and immunosuppressives are all noted treatment
options for SLE, antiplatelet aggregators are unlikely to address the etiology or signs
and symptoms of the disease. A new drug that has shown positive effects in decreasing
inflammatory exacerbations for people with SLE is Belimumab, which is a monoclonal
antibody that inhibits B-lymphocyte stimulator.
- A 36-year-old female who has experienced diverse symptoms for several years has
finally had her health problems attributed to scleroderma (systemic sclerosis) and has
committed herself to learning as much about the disease as she can. Which of her
following statements would her nurse want to correct or clarify?
A) “I’m surprised that in this day and age, they still don’t know what causes
scleroderma.”
B) “I suppose this explains why I have such terrible circulation to my hands and
feet.”
C) “I’m scared by the damage that this could cause to my heart and lungs.”
D) “The worst part of this so far has been learning that there aren’t any treatments for
scleroderma.”
Ans: D
Feedback:
While the cause of scleroderma remains unknown, supportive treatments that address
symptoms do exist. Reynaud phenomenon is a very common accompaniment to the
disease, and cardiac and pulmonary involvement is common.
- When working with a patient with diffuse scleroderma who is exhibiting a “stone face”
expression, the nurse should consider which of the following to be a priority nursing
diagnosis for this patient?
A) Ineffective tissue perfusion related to tightening of the facial skin
B) Activity intolerance related to muscle tightening in lower extremities
C) Oral mucous membrane, impaired due to restricted motion of the mouth
D) Aspiration, risk related to swallowing impairments
Ans: D
Feedback:
Diffuse scleroderma is characterized by severe and progressive disease of the skin and
the early onset of organ involvement. The typical person has a “stone facies” due to
tightening of the facial skin with restricted motion of the mouth. Involvement of the
esophagus leads to hypomotility and difficulty in swallowing. The other NANDAs
would be of lower priority if at all given the assessment data presented.
- A 16-year-old boy has been diagnosed with ankylosing spondylitis. Which of the
following etiologies is responsible for his health problem?
A) Infection
B) Friction between bones
C) Immune response
D) Inappropriate bone remodeling
Ans: C
Feedback:
Ankylosing spondylitis is thought to have an etiology that suggests an immune
response. Physical wear and tear, infection, and inappropriate remodeling are not
considered primarily responsible for the disease.
- Which of the following pathophysiological phenomena would be most indicative of
ankylosing spondylitis?
A) Loss of motion in the spinal column and eventual kyphosis
B) A progressive loss of range of motion in the knee and hip joints
C) A facial “butterfly rash” and multiorgan involvement
D) Decreased bone density in long bones
Ans: A
Feedback:
The characteristic trait of ankylosing spondylitis is progressive loss of the spinal ROM
and eventual kyphosis. Synovial joint involvement is not associated with the disease,
and a butterfly rash and multisystem involvement are associated with SLE. Decreased
bone density does not normally accompany ankylosing spondylitis.
- When educating the patient with ankylosing spondylitis, the nurse should emphasize
which of the following treatment interventions? Select all that apply.
A) Encourage sleeping supine on an extra firm mattress if possible.
B) Prop self up in bed with extra pillows if having respiratory congestion.
C) Try using the heating pad prior to exercise to help stretching and improve
movement.
D) Wear a knee immobilizer while biking to facilitate ability to exercise for longer
periods.
E) Modify diet to include more protein from red meats and green vegetables for
vitamin K.
Ans: A, C
Feedback:
Treatment of ankylosing spondylitis is directed at controlling pain and maintaining
mobility by suppressing inflammation. Proper posture and position are important. This
includes sleeping in a supine position on a firm mattress using one small pillow.
Therapeutic exercises are important. Heat applications or a shower or bath may be
beneficial before exercise to improve ease of movement. Swimming is an excellent
exercise. Immobilizing joints is not recommended. Maintaining ideal weight reduces the
stress on weight-bearing joints. However, dietary changes are usually very
individualized.
- Which of the following individuals is most likely to develop a form of reactive arthritis?
A) A 24-year-old male who completed treatment for a chlamydial infection 1 year
ago
B) A 46-year-old female who has a long-standing diagnosis of systemic lupus
erythematosus
C) A 3-year-old girl who was born with a 20-degree congenital scoliosis
D) A 79-year-old male who had a total hip replacement 2 months prior
Ans: A
Feedback:
Reactive arthritis and Reiter syndrome, in particular, are precipitated by time-distant
bacterial infections; Chlamydia trachomatis is frequently implicated. SLE, scoliosis, and
hip fractures and/or surgery are not noted risk factors for the health problem.
- While speaking to a senior citizen club about osteoarthritis (OA), which of the following
facts are accurate to share? Select all that apply.
A) By the time you are in your 70s, about 85% of adults will have some form of OA
B) Men usually get OA in their hands, whereas women get OA primarily in their hips
C) Obesity in women has been correlated to having OA in the knees
D) Heredity does not play a significant role in the development of OA
Ans: A, C
Feedback:
Eighty-five percent of people with OA are in their 70s. Men are affected more
commonly at a younger age. Heredity influences the occurrence of hand OA in the DIP
joint. Hand OA is more likely to affect white women, whereas knee OA is more
common in black women. Obesity is a particular risk factor for OA of the knee in
women.
- Due to her progressing osteoarthritis (OA), an 80-year-old woman is no longer able to
perform her activities of daily living without assistance. Which of the following
phenomena most likely underlies the woman’s situation?
A) Inappropriate T-cell–mediated immune responses have resulted in articular
cartilage degeneration.
B) Loss of articular cartilage and synovitis has resulted from inflammation caused
when joint cartilage attempted to repair itself.
C) Excessive collagen deposits have accumulated in the woman’s synovial joints.
D) Bone overgrowth in synovial joints has resulted in fusing of adjacent bones that
normally articulate.
Ans: B
Feedback:
The joint changes associated with osteoarthritis, which include a progressive loss of
articular cartilage and synovitis, result from the inflammation caused when cartilage
attempts to repair itself, creating osteophytes or spurs. These changes are accompanied
by joint pain, stiffness, limitation of motion, and in some cases by joint instability and
deformity. Immune etiology is more associated with rheumatoid arthritis, and collagen
deposits are characteristic of scleroderma. Bones do not tend to fuse in the pathogenesis
of OA.
- A 64-year-old man was diagnosed 19 months ago with bilateral osteoarthritis (OA) in
his knees, and has come to his family physician for a checkup. The client and his
physician are discussing the effects of his health problems and the measures that the man
has taken to accommodate and treat his OA in his daily routines. Which of the following
statements by the client would necessitate further teaching?
A) “I’m really trying to lose weight, and I’ve been able to lose 15 lb this year so far.”
B) “I’ve been doing muscle-strengthening exercises twice a week at the community
center near my house.”
C) “Even though I don’t like it, I’ve been using my walker to take some of the weight
off my knees.”
D) “I’ve been avoiding painkillers because I know they can mask damage that I might
be inflicting on my knees.”
Ans: D
Feedback:
Analgesics are a common and appropriate treatment for OA, and it would be
unnecessary and inappropriate to forego pain control in order to maximize pain signals
from affected joints. Weight loss, the use of assistive devices, and muscle-strengthening
exercises are appropriate treatments for OA.
