Chapter 51 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 51

Question 1

Type: MCMA

The nurse is preparing for a community education session on autoimmune disorders. The nurse should review information about which diseases?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Scleroderma

2. Rheumatoid arthritis (RA)

3. Gouty arthritis

4. Systemic lupus erythematosus (SLE)

5. Reactive arthritis

Correct Answer: 1,2,4

Rationale 1: The cause of scleroderma is unknown, but it is thought to be autoimmune.

Rationale 2: Rheumatoid arthritis is thought to be an autoimmune disorder.

Rationale 3: Gouty arthritis is thought to have a hereditary component, with a defect in purine metabolism. It is not an autoimmune disorder.

Rationale 4: SLE is a chronic inflammatory autoimmune disease that attacks connective tissue or organs.

Rationale 5: Reactive arthritis is a type of arthritis that develops soon after or during an infection somewhere else in the body.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 51-1

Question 2

Type: MCMA

A patient diagnosed with rheumatoid arthritis (RA) is reluctant to start some recommended therapies. The nurse tells the patient that early intervention is crucial for long-term health. What rationales would the nurse provide for this statement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Early intervention is instrumental in bringing about long-term remission of symptoms.

2. Beginning treatment early can help control pain generated by the disorder.

3. If the disease is not treated, tissue and joint damage can be extreme.

4. Early and aggressive exercise will help keep joints mobile.

5. If treatment is started early, joint deformity can be avoided.

Correct Answer: 2,3

Rationale 1: RA is a chronic condition without a cure or long-term remission.

Rationale 2: RA is a painful condition that requires a combination of therapeutic approaches to treatment. Early treatment of pain helps maintain joint function.

Rationale 3: Treatment can help reduce the amount of tissue and joint damage. If treatment is started earlier, rather than later, tissue and joint damage can be minimized.

Rationale 4: Exercise should be balanced with rest, and joints should be safeguarded.

Rationale 5: Joint deformity is likely to occur despite early treatment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-2

Question 3

Type: MCSA

A patient diagnosed with gouty arthritis is prescribed the drug colchicine to reduce symptoms. Which medication education should the nurse provide?

1. There is a possibility of orthostatic hypotension.

2. A diet with fewer restrictions on purine ingestion may be adopted.

3. The pain will diminish, but the joint will remain swollen and red.

4. Vomiting and/or diarrhea are common side effects of this medication.

Correct Answer: 4

Rationale 1: Orthostatic hypotension is not a typical side effect of colchicines.

Rationale 2: The patient should remain on a low-purine diet as part of the treatment plan.

Rationale 3: Colchicine exerts an anti-inflammatory effect and reduces pain and swelling.

Rationale 4: Nausea, vomiting, and diarrhea are among the early signs of colchicine toxicity. These effects would necessitate changing the medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 51-6

Question 4

Type: MCMA

The nurse has completed a health assessment, physical examination, and interview with a patient. Which assessment data would support a diagnosis of reactive arthritis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The conjunctiva of the right eye is reddened, with a thin, watery drainage.

2. The patient reports increased urine output.

3. The patient reports having food poisoning 12 days ago.

4. The patient reports pain in both knees.

5. The patients right ankle is swollen only on the medial side.

Correct Answer: 1,3,4,5

Rationale 1: Conjunctivitis and unilateral uveitis are clinical manifestations associated with reactive arthritis.

Rationale 2: Increased urine output is not associated with reactive arthritis.

Rationale 3: Assessment data supporting a diagnosis of reactive arthritis would include gastrointestinal bacterial infection 1 to 3 weeks prior to the outbreak of symptoms.

Rationale 4: Joint pain is associated with reactive arthritis.

Rationale 5: Asymmetrical joint swelling is common in the lower extremities.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 51-5

Question 5

Type: MCMA

A patient has been admitted for treatment of early-stage Lyme disease. The nurse would assess for which findings usually associated with this stage of the illness?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Stiff neck

2. Forgetfulness

3. Bulls-eye rash

4. Painful urination

5. Poor motor balance

Correct Answer: 1,2,3

Rationale 1: The first stage of Lyme disease includes flulike symptoms, including a stiff neck.

Rationale 2: The early localized symptoms include forgetfulness.

Rationale 3: Assessment of the early localized disease, the first stage, includes evaluating for a growing rash called erythema chronicum migrans (ECM). ECM looks like a bulls eye on the affected part.

Rationale 4: Painful urination is not a symptom of any stage of Lyme disease.

Rationale 5: Poor motor balance is associated with the second stage of Lyme disease and occurs a couple of weeks to months after infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 51-5

Question 6

Type: MCMA

A patient diagnosed with scleroderma reports heartburn. Which instructions would the nurse provide for treatment of this symptom?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Drink only decaffeinated beverages.

2. Use the nicotine patches as prescribed.

3. Increase fiber in the diet.

4. Elevate the head of the bed to 30 degrees.

5. Take omeprazole (Prilosec) as prescribed.

Correct Answer: 1,2,4,5

Rationale 1: Scleroderma can affect the esophagus. Avoidance of caffeine may help alleviate heartburn symptoms.

Rationale 2: Patients should attempt smoking cessation.

Rationale 3: Fiber in the diet will help relieve constipation but would not address heartburn.

Rationale 4: Elevating the head of the bed can reduce the backflow of acid into the esophagus that causes inflammation and heartburn.

Rationale 5: Medications used to treat esophagus irritation and heartburn include omeprazole (Prilosec).

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-4

Question 7

Type: MCMA

The nurse is preparing a flyer on rheumatoid arthritis (RA) for distribution during a community health fair. Which information should the nurse include?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Rheumatoid arthritis typically affects weight-bearing joints.

2. Onset generally occurs between 20 and 40 years of age.

3. Rheumatoid arthritis is the most common form of arthritis.

4. Women are more likely to be affected than men.

5. Rheumatoid arthritis appears to have a genetic component.

Correct Answer: 2,4,5

Rationale 1: RA most often affects the joints of the hands and feet. Osteoarthritis affects weight-bearing joints.

Rationale 2: RA can occur at any age, with the peak incidence between ages 20 and 40.

Rationale 3: Osteoarthritis (OA) is the most common form of arthritis.

Rationale 4: RA affects three times more women than men worldwide.

Rationale 5: RA is thought to be an autoimmune disorder that not only involves tissue hypersensitivity but also has a genetic component.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-2

Question 8

Type: MCMA

A patient is receiving a series of diagnostic tests to confirm the diagnosis of osteoarthritis (OA). The nurse would interpret which results as supporting the diagnosis of OA?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Presence of antinuclear antibodies in blood

2. Asymmetrical joint cartilage loss seen on X-ray

3. Increased erythrocyte sedimentation rate (ESR) in blood

4. Bone spurs visible on computed tomography (CT)

5. Increased bone density in Dexa scan

Correct Answer: 2,3,4,5

Rationale 1: The presence of antinuclear antibodies in blood is reflective of RA, not OA.

Rationale 2: Asymmetrical joint cartilage loss is a positive diagnostic result for OA.

Rationale 3: Increased ESR is a positive diagnostic result for OA.

Rationale 4: Bone spurs are a positive diagnostic result for OA.

Rationale 5: Increased bone density is a positive diagnostic result for OA.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 51-2

Question 9

Type: MCSA

The nurse is providing dietary education for a patient recently diagnosed with a form of arthritis. The patient is encouraged to avoid alcohol, organ meats, and dried peas, beans, and peanuts. These recommendations are appropriate for patients with which specific diagnosis?

1. Rheumatoid arthritis

2. Reactive arthritis

3. Osteoarthritis

4. Gouty arthritis

Correct Answer: 4

Rationale 1: These dietary restrictions are not necessary for patients with RA.

Rationale 2: These dietary restrictions are not necessary for patients with reactive arthritis.

Rationale 3: These dietary restrictions are not necessary for patients with OA.

Rationale 4: Because gouty arthritis is caused by indulging in foods high in purines, it can be controlled by eating a well-balanced, low-calorie, low-purine diet and by reducing alcohol consumption. Foods to be avoided are alcohol, organ meats, and rich foods such as gravies, dried legumes, and anchovies.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-2

Question 10

Type: MCSA

The nurse is discussing the symptomology of osteoarthritis (OA) with a patient. The nurse would describe which common initial symptom of the disease?

1. A fine red rash on the elbow that is constant

2. Painful stiffness in the joints of the fingers

3. Popping sensation in the wrist joint when typing

4. Knee pain when the leg is at rest

Correct Answer: 2

Rationale 1: A red rash is not a typical indicator of OA.

Rationale 2: The onset of osteoarthritis (OA) is gradual and progressive. The symptoms that are noticed first are pain and stiffness in the affected joint or joints.

Rationale 3: Crepitus (grating, crackling, or popping sounds experienced at a joint) is a late sign of OA in a joint.

Rationale 4: Pain at rest is a late sign of OA in a joint.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 51-2

Question 11

Type: MCMA

A patient with a history of rheumatoid arthritis reports mobility impairment as a result of hip and knee joint stiffness. Which intervention should the nurse include in an education session to address this problem?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Encouraging frequent periods of rest for the affected hip and knee joints

2. Educating the patients family to perform passive range-of-motion exercises of the affected joints

3. Instructing the patient in the proper technique for active range of motion of the affected joints

4. Discussing the use of relaxation techniques when affected joints are most painful

5. Suggesting the application of ice to the affected joints to minimize pain

Correct Answer: 1,2,3

Rationale 1: It is necessary to rest when the disease process flares up.

Rationale 2: Passive range-of-motion exercises will help maintain maximum joint mobility.

Rationale 3: Active range-of-motion exercises will help maintain maximum joint mobility.

Rationale 4: Relaxation techniques are directed toward pain management, not joint mobility.

Rationale 5: The application of heat is more appropriate because it will facilitate movement of the joints while also impacting the inflammatory process.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-2

Question 12

Type: MCSA

Impaired physical mobility is a major nursing diagnosis for patients with osteoarthritis (OA). Which intervention would be most effective in addressing this patients limitation?

1. Assessing the patients range of motion of affected joints in order to plan and implement appropriate interventions

2. Encouraging the patient to assume responsibility for personal self-care needs in order to remain physically active

3. Encouraging consistently high activity levels in order to minimize the development of associated emotional and self-esteem problems

4. Assessing and managing the patients need for narcotic analgesics in order to minimize the impact of pain on personal activities of daily living

Correct Answer: 1

Rationale 1: A determination of the patients range of motion is needed to provide the best individualized care.

Rationale 2: Assuming responsibility for personal self-care needs may not be realistic for all patients with OA.

Rationale 3: Simply encouraging the patient to remain active does not provide comprehensive care.

Rationale 4: Pharmacologic intervention includes many more classes of drugs. The intervention should be to manage the pharmacologic regimen, not specifically to manage one drug class.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 51-3

Question 13

Type: MCSA

The patient has experienced an exacerbation of gout resulting in foot pain. Which nursing intervention would aid in promoting comfort?

1. Providing passive range-of-motion exercises

2. Wrapping the extremity in an elastic bandage

3. Encouraging liberal fluid intake

4. Elevating the extremity

Correct Answer: 4

Rationale 1: Range-of-motion exercises may increase discomfort.

Rationale 2: The pressure of the elastic bandage over the affected joint may increase pain.

Rationale 3: Fluid intake is encouraged but will not directly reduce the patients discomfort.

Rationale 4: The pain in the affected extremity will be lessened with elevation; elevation will reduce inflammation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-2

Question 14

Type: MCMA

A patient is experiencing symptoms typical of gout in the right foot. The nurse would prepare the patient for which diagnostic examinations?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. MRI of the affected foot

2. Joint aspiration

3. Serum uric acid level

4. CT of the affected foot

5. X-ray of the affected foot

Correct Answer: 2,3,5

Rationale 1: An MRI is not likely to be needed to assess gout.

Rationale 2: Joint aspiration is performed to differentiate gout from infectious processes in the joint.

Rationale 3: Serum uric acid levels are often drawn in the diagnosis of gout. However, not all persons with gout have elevated uric acid levels, and some persons who do not have gout have increased levels.

Rationale 4: A CT is not likely to be necessary to diagnose gout.

Rationale 5: An X-ray would be appropriate to assess underlying joint damage, especially in patients who have had multiple episodes of gouty arthritis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 51-2

Question 15

Type: MCMA

The nurse is preparing discharge medication instructions for a patient who has been prescribed allopurinol (Aloprim). Which information should the nurse include?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Adverse reactions to the medication include sore throat, bruising, and fever.

2. Keep scheduled appointments for the monitoring of prothrombin time.

3. Increase fluid intake while taking this medication.

4. Take the medication as prescribed, following meals.

5. Maintain current weight with the inclusion of calorie-dense foods.

Correct Answer: 3,4

Rationale 1: Sore throat, bruising, and fever are adverse effects of colchicine, not allopurinol.

Rationale 2: Prothrombin time is not usually monitored for patients prescribed allopurinol.

Rationale 3: Patients taking allopurinol should increase fluid intake.

Rationale 4: The medication should be taken after a meal to reduce gastric distress.

Rationale 5: Gouty arthritis is seen more frequently in patients who are overweight, so the inclusion of calorie-dense foods would not be encouraged.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 51-2

Question 16

Type: MCSA

A patient diagnosed with gout is concerned that the small lumps on his ear and big toe will become lodged in his blood, resulting in a blood clot. Which explanation by the nurse is most accurate?

1. Clots will not develop if you take your antigout medicine.

2. Unfortunately, this is a common complication associated with gout.

3. You will need to talk with the physician during your next visit.

4. These lumps do not cause clots.

Correct Answer: 4

Rationale 1: This statement is not accurate. The deposits do not form clots.

Rationale 2: Tophi are common complications associated with gout. However, this statement does not explain that the lumps will not cause blood clots.

Rationale 3: Advising the patient to wait until a future visit to discuss the concern is not appropriate, as the patient is seeking information at the present time.

Rationale 4: The deposits are known as tophi. They result from uric acid crystal buildup and develop most often in locations with lower body temperature readings. They do not cause clots.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-2

Question 17

Type: SEQ

A patient is newly diagnosed with osteoarthritis. List the nursing diagnoses for this patient in the order of their priority.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Imbalanced Nutrition: Less than Body Requirements related to inadequate intake of calcium

Choice 2. Risk for Injury related to effects of change in bone structure secondary to osteoarthritis

Choice 3. Acute Pain of the Lower Spine related to vertebral compression

Choice 4. Deficient Knowledge related to osteoarthritis and treatment to prevent further damage

Correct Answer: 3,2,1,4

Rationale 1: The patient should be evaluated and treated for a deficiency of dietary calcium and vitamin D and provided information about supplementation. This physical need is priority after pain is controlled and risk of injury is minimized.

Rationale 2: The second priority would be to ensure that the patient is reducing the risk of falls and injury related to the osteoarthritis.

Rationale 3: Pain control is the first priority. Every patient has the right to relief of pain.

Rationale 4: The education of this patient will encompass all aspects of the management and treatment of osteoarthritis. This is an important nursing diagnosis that is prioritized after pain, risk of injury, and balanced nutrition have been addressed.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 51-3

Question 18

Type: MCSA

A butterfly rash on the face is characteristic of which inflammatory connective tissue disease?

1. Rheumatoid arthritis

2. Systemic lupus erythematosus (SLE)

3. Pagets disease

4. Gout

Correct Answer: 2

Rationale 1: Rheumatoid arthritis does not present with a rash.

Rationale 2: Most people with SLE have skin manifestations at some point during their disease. SLE was originally described as a skin disorder and named for the characteristic red butterfly rash across the cheeks and bridge of the nose.

Rationale 3: Patients with Pagets disease do not have a rash.

Rationale 4: Patients with gout do not have a rash.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 51-4

Question 19

Type: MCSA

The patient presents with contracture deformities of the hand and complains of severe pain. What musculoskeletal disorder does this patient manifest?

1. Rheumatoid arthritis

2. Osteomyelitis

3. Osteoporosis

4. Ankylosing spondylitis

Correct Answer: 1

Rationale 1: The pattern of joint involvement in rheumatoid arthritis (RA) is typically polyarticular and symmetric. The proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints of the fingers, wrists, knees, ankles, and toes are most frequently involved, although RA can affect any joints.

Rationale 2: Osteomyelitis is an infection of the bone and does not result in contracture deformities. It may cause localized tenderness and other signs of infection such as fever, swelling, erythema, and lymph node involvement.

Rationale 3: Osteoporosis may cause pathologic fractures but does not cause joint deformity.

Rationale 4: Ankylosing spondylitis is a chronic inflammatory arthritis that primarily affects the axial skeleton and leads to pain and progressive stiffness of the spine.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 51-2

Question 20

Type: MCMA

Diagnostic procedures are being performed on a female patient who may have systemic lupus erythematosus (SLE). Which findings would the nurse evaluate as supporting this diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Elevated LE prep

2. Hematuria

3. Negative anti-SM antibody

4. C3 complement protein of 94 mg/dL

5. Sodium 138

Correct Answer: 1,2

Rationale 1: An elevated LE prep supports the diagnosis of SLE, as there are normally no LE cells present.

Rationale 2: Hematuria is often present in patients with SLE.

Rationale 3: The normal result of this test is negative. The presence of anti-SM antibodies supports the diagnosis of SLE.

Rationale 4: The C3 normal range for females is 76120 mg/dL. SLE reduces these levels.

Rationale 5: Sodium levels are not used to diagnose SLE.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 51-4

Question 21

Type: MCMA

A patient diagnosed with systemic lupus erythematosus exhibits a facial rash. What instruction should the nurse provide regarding skin care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Avoid being out of doors during the hours of greatest sun intensity.

2. Use sunscreen if sun exposure is possible.

3. Apply hydrocortisone cream 1% to the rash 4 to 6 times per day.

4. Wash the rash with antibacterial soap three times a day.

5. Swim in a chlorinated pool for relief of burning.

Correct Answer: 1,2

Rationale 1: The patient should avoid being out of doors during peak sunlight hours.

Rationale 2: The patient should use sunscreen if sun exposure is possible.

Rationale 3: There is no indication that hydrocortisone cream should be applied to this rash.

Rationale 4: The skin should be kept clean, but mild soap should be used. There is no reason to wash the area three times a day.

Rationale 5: The rash does not burn. There is no indication that chlorinated pool water promotes comfort.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-4

Question 22

Type: MCSA

A 20-year-old male patient is scheduled for an echocardiogram. The patient says, I dont understand why this test is necessary when I came in for back and hip pain. The nurse considers which information before responding?

1. Cardiac pain often refers to the back.

2. Ankylosing spondylitis also affects the heart.

3. The patient likely has septic arthritis, which can be caused by congenital heart disorders.

4. Young males often develop back pain as a sign of dissecting aortic aneurysm.

Correct Answer: 2

Rationale 1: The pain of myocardial infarction may refer to the back, but this disorder would be unlikely in the patient.

Rationale 2: Back and hip pain in a young male may be associated with ankylosing spondylitis. AK also affects cardiac tissues.

Rationale 3: Septic arthritis is caused by infection.

Rationale 4: Dissecting aortic aneurysms are more common in older men. There is no additional assessment finding to suggest this disorder in this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-2

Question 23

Type: MCSA

A patient reports using aspirin for years to control severe arthritis pain because acetaminophen and NSAIDs just dont work well for me. The nurse would advise the patient of which sign of aspirin toxicity?

1. Seeing halos around lights

2. Intermittent red, itchy skin rash

3. Ringing in the ears

4. Ankle edema

Correct Answer: 3

Rationale 1: Seeing halos around lights is a sign of digoxin toxicity and is not associated with aspirin toxicity.

Rationale 2: Allergy to aspirin can result in a rash, but this patient has been taking the drug for some time.

Rationale 3: Ringing in the ears is a sign of aspirin toxicity.

Rationale 4: Ankle edema is not associated with aspirin toxicity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-2

Question 24

Type: MCSA

The nurse has chosen these nursing diagnoses for a patient who has systemic lupus erythematosus. Which NDX would be assigned the highest priority?

1. Skin Integrity: Impaired

2. Activity Intolerance

3. Anxiety

4. Fluid Volume Excess

Correct Answer: 2

Rationale 1: Impaired Skin Integrity is applicable to most patients with SLE, but this is not the NDX of highest priority.

Rationale 2: Inability to tolerate activity is the highest priority of the NDX listed. Patients should be taught to balance rest and activity.

Rationale 3: The patient with SLE is likely to be anxious about the disease process and its effect on daily life. This is not the NDX of highest priority.

Rationale 4: The patient with SLE may have fluid volume problems if kidney function is impaired. This is not the NDX of highest priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 51-1

Question 25

Type: MCSA

The nurse would evaluate that a patient with systemic lupus erythematosus understands dietary teaching when the patient selects which food for breakfast?

1. Orange juice

2. Sausage, gravy, and biscuits

3. A doughnut

4. Toast

Correct Answer: 1

Rationale 1: The patient with SLE requires additional vitamin C.

Rationale 2: Generally, the diet should be low in sodium.

Rationale 3: Food choices should reflect a healthy, balanced diet.

Rationale 4: There is no particular reason that toast is not a good choice, but it does not offer any special benefit, either. Another choice would be healthier for this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 51-4

Question 26

Type: MCSA

The nurse has been providing care to a patient with scleroderma for a number of years. As the patients disease progresses, the nurse monitors for CREST symptomology. For which finding is the nurse assessing?

1. Recurrence of tophi on the ears or fingers

2. Shiny skin over the involved joints.

3. Development of telangiectasia

4. Extremities that are always cool to the touch

Correct Answer: 3

Rationale 1: The R of CREST represents Raynauds -type symptoms.

Rationale 2: The S of CREST represents sclerodactyly.

Rationale 3: Development of telangiectasia is represented by the T in CREST.

Rationale 4: The C in CREST represents calcium deposits.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 51-4

Question 27

Type: MCSA

The nurse is monitoring a patient diagnosed with scleroderma for the development of sclerodactyly. Which area would the nurse assess?

1. The posterior neck

2. The knees

3. The chest wall

4. The fingers

Correct Answer: 4

Rationale 1: The posterior neck is not where sclerodactyly develops.

Rationale 2: The knees are not where sclerodactyly develops.

Rationale 3: Sclerodactyly does not develop in the chest wall.

Rationale 4: Sclerodactyly is the thickening, induration, and tightening of the skin of the fingers.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 51-4

Question 28

Type: MCMA

A patient diagnosed with scleroderma has been prescribed methotrexate (Rheumatrex). Which medication teaching should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Use sunblock when outside.

2. Avoid caffeine.

3. Avoid citrus juices.

4. Do not take aspirin with this drug.

5. Do not use any over-the-counter medication without first checking with the health care provider.

Correct Answer: 1,2,4,5

Rationale 1: Methotrexate causes photosensitivity, so sunblock should be used.

Rationale 2: Caffeine can cause increased toxicity of methotrexate.

Rationale 3: There is no specific restriction on drinking citrus juices.

Rationale 4: There is an adverse drugdrug reaction between methotrexate and aspirin.

Rationale 5: Many OTC products interact with methotrexate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-4

Question 29

Type: MCSA

A woman calls the emergency department and says, I just found a tick crawling on my son. What can I do to keep him from getting Lyme disease? How should the nurse respond?

1. Bring him in so that we can give him a prescription for amoxicillin.

2. The tick can transmit the disease only if it bit your child.

3. He needs an injection of gamma globulin.

4. Unless the tick is bigger than a pencil eraser, there is no reason to be alarmed.

Correct Answer: 2

Rationale 1: There is no information that indicates this child has Lyme disease and needs treatment.

Rationale 2: The disease is transmitted by the bite of the tick, not by its presence on the skin.

Rationale 3: An injection of gamma globulin is not indicated. There is no indication that the child has been exposed.

Rationale 4: Lyme disease is spread by deer ticks, which are very small.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-6

Question 30

Type: MCSA

A patient with Sjgrens syndrome is scheduled to be seen in the clinic this afternoon. The nurse would anticipate treating which symptom?

1. Dry eyes

2. Muscle pain in the back

3. Pulmonary congestion

4. Rhinorrhea

Correct Answer: 1

Rationale 1: The two primary manifestations of Sjgrens syndrome are dry eyes and dry mouth.

Rationale 2: Muscle pain in the back is not associated with Sjgrens syndrome.

Rationale 3: Sjgrens syndrome causes a drying of tissues, not congestion.

Rationale 4: Sjgrens syndrome causes dryness of tissues.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 51-4

Question 31

Type: MCSA

A 59 year-old female is being evaluated for presence of a connective tissue disease. The erythrocyte sedimentation rate (ESR) result is reported as 26 mm/hour. How would the nurse evaluate this result?

1. The ESR is very low, indicating that the patient has an autoimmune disorder rather than a connective tissue disorder.

2. This is a normal finding, so no connective tissue disease is present.

3. The ESR is high, so inflammatory disease is present.

4. The ESR is normal and other testing is indicated.

Correct Answer: 4

Rationale 1: The ESR is normal for a patient of this age and gender.

Rationale 2: The ESR is normal, but connective tissue disease could still be present.

Rationale 3: The ESR is normal for a woman this age.

Rationale 4: As the ESR is normal, other testing may be done to determine the source of the patients discomfort.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 51-1

Question 32

Type: MCSA

A patient with rheumatoid arthritis is prescribed infliximab (Remicade). Which nursing diagnosis does the nurse include as priority in the patients plan of care?

1. Risk for Ineffective Tissue Perfusion

2. Risk for Infection

3. Disturbed Body Image

4. Anxiety

Correct Answer: 2

Rationale 1: There is no indication that treatment with infliximab will directly or immediately increase the patients risk for ineffective tissue perfusion.

Rationale 2: There is a black box warning with infliximab and development of tuberculosis.

Rationale 3: The use of infliximab should not alter the patients body image.

Rationale 4: The use of infliximab should not increase the patients anxiety.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 51-3

Question 33

Type: MCSA

A patient says, My physician thinks I may have psoriatic arthritis, but there is nothing wrong with my skin. How should the nurse respond?

1. You must have a subclinical case of psoriasis.

2. You will probably develop skin eruptions in a few years.

3. Not all people with psoriatic arthritis also have psoriasis.

4. There are other arthritis conditions that have similar laboratory values, so additional testing will be likely.

Correct Answer: 3

Rationale 1: This statement is inaccurate.

Rationale 2: This statement is inaccurate.

Rationale 3: Psoriatic arthritis is not always associated with psoriasis.

Rationale 4: This is a true statement but implies that the current diagnosis is wrong.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-4

Question 34

Type: MCSA

A patient diagnosed with reactive arthritis says, I know this condition came from an infection. Can I give it to my family? How should the nurse respond?

1. You will be contagious until you have been on the prescribed antibiotics for 3 to 4 days.

2. If your family was going to catch this, they probably already have.

3. Your arthritis was caused by an infection that you might be able to pass on to your family, but you cannot give them arthritis.

4. The kind of infection that causes this arthritis is not communicable.

Correct Answer: 3

Rationale 1: Antibiotics will be used only if the patient still has the infection. The disorder is not communicable.

Rationale 2: The disorder is not communicable.

Rationale 3: Reactive arthritis is caused by an infection. The infection may be communicable and passed to others, but not all those with the infection will develop arthritis. The arthritis disorder is not communicable.

Rationale 4: Infections that cause reactive arthritis are communicable.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-4

Question 35

Type: MCSA

A patient diagnosed with rheumatoid arthritis is prescribed hydroxychloroquine (Plaquenil). What medication information should the nurse provide?

1. Come back to the clinic after you have taken the medication for 2 full days so we can draw a blood level.

2. Take this first thing in the morning and do not eat for at least 45 minutes.

3. You may notice that your hair becomes lighter while taking this medication.

4. Constipation is a frequent side effect of this medication.

Correct Answer: 3

Rationale 1: There is no need to draw a blood level of the medication in 2 days.

Rationale 2: The drug should be taken with food.

Rationale 3: This medication may cause bleaching of the hair.

Rationale 4: Diarrhea is a frequent side effect of this medication.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 51-2

 

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