Nokea
The nurse is caring for a patient with polymyositis and has joint pain, an erythematous facial rash with eyelid edema, and a weak, hoarse voice. Which of the following nursing diagnoses is priority?
- A. Acute pain related to biological injury agent (inflammation)
- B. Risk for aspiration as evidenced by barrier to elevating upper body
- C. Risk for impaired skin integrity as evidenced by excretions
- D. Risk for dry eye as evidenced by insufficient knowledge of modifiable factors (eyelid swelling)
Correct Answer: B
Rationale: The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other nursing diagnoses also are appropriate but are not as high a priority as the maintenance of the patient's airway.
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The nurse is caring for a patient in a long-term care facility who takes multiple medications and has developed acute gouty arthritis. Which of the following medications should not be given until the health care provider has been consulted?
- A. Serratiopeptidase
- B. Famotidine
- C. Oxycodone
- D. Hydrochlorothiazide
Correct Answer: D
Rationale: Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.
To determine whether a patient with joint swelling and pain has systemic lupus erythematosus, which test will be most useful for the nurse to review?
- A. Rheumatoid factor (RF)
- B. Antinuclear antibody (ANA)
- C. Anti-Smith antibody (Anti-Sm)
- D. Lupus erythematosus (LE) cell prep
Correct Answer: C
Rationale: The anti-Sm is an antibody found almost exclusively in SLE. The other blood tests also are used in screening but are not as specific to SLE.
The nurse is caring for a young adult patient with urethritis and knee pain who has been diagnosed with reactive arthritis. Which of the following medications should the nurse include in the teaching plan?
- A. Anakinra
- B. Etanercept
- C. Doxycycline
- D. Methotrexate
Correct Answer: C
Rationale: Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and treatment with doxycycline. The other medications are used for persistent inflammatory problems such as rheumatoid arthritis.
The nurse is caring for a patient with dermatomyositis who is receiving long-term prednisone therapy. Which of the following findings is most important to report to the health care provider?
- A. The blood glucose is 6.2 mmol/L.
- B. The patient has painful hematuria.
- C. The patient has an increased appetite.
- D. Acne is noted on the back and face.
Correct Answer: B
Rationale: Corticosteroid use is associated with increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne also are adverse effects of corticosteroid use, but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.
The nurse is caring for a patient with gout and has a red, painful left great toe. Which of the following nursing actions should be included in the plan of care?
- A. Gently palpate the toe to assess swelling.
- B. Use pillows to keep the left foot elevated.
- C. Use a footboard to hold bedding away from the toe.
- D. Teach patient to avoid use of acetaminophen.
Correct Answer: C
Rationale: Since any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by the urate crystals. Acetaminophen can be used for pain relief.