A nurse is assessing a 45-year-old client with a 3-year hist… | 마이메르시 MyMerci
Adult Health
문제
A nurse is assessing a 45-year-old client with a 3-year history of rheumatoid arthritis. Which assessment finding would be most characteristic of this autoimmune condition?
1Asymmetrical joint involvement with bony enlargement
2Bilateral symmetrical joint swelling with morning stiffness lasting over 1 hour✓ 정답
3Joint pain that worsens with activity and improves with rest
4Localized joint inflammation affecting only weight-bearing joints
해설
Rheumatoid arthritis is characterized by bilateral symmetrical joint swelling and morning stiffness lasting over 1 hour, distinguishing it from other arthritic conditions. Other options describe features of osteoarthritis or localized inflammation.
심화 해설
Core Nursing ExplanationKey Concept Analysis: This question tests your ability to differentiate between the hallmark clinical features of Rheumatoid Arthritis (RA) and other forms of arthritis, particularly Osteoarthritis (OA). RA is a chronic, systemic autoimmune disorder where the body's immune system mistakenly attacks the synovial membranes lining the joints. This leads to persistent inflammation, synovial proliferation (pannus formation), and eventual joint destruction. The key features stem from this systemic, inflammatory process.
Answer Rationale: Key Point! The correct answer is Bilateral symmetrical joint swelling with morning stiffness lasting over 1 hour. This combination is the classic presentation of RA.
Symmetry: The autoimmune process affects joints on both sides of the body equally (e.g., both wrists, both MCP joints).
Morning Stiffness: Prolonged stiffness (often 30 minutes to several hours) after periods of inactivity is a direct result of overnight accumulation of inflammatory mediators and edema in the synovium. This stiffness improves with gentle activity and use.
Swelling: This is due to synovitis (inflammation of the synovial membrane) and joint effusion, giving the joints a soft, "boggy," or spongy feel on palpation.
Distractor Analysis:
Watch out for confusion!Option 1: "Asymmetrical joint involvement with bony enlargement" describes Osteoarthritis (OA). OA is a degenerative "wear-and-tear" disease, not autoimmune. It typically affects joints asymmetrically (e.g., one knee more than the other) and causes bony overgrowths called Heberden's nodes (DIP joints) and Bouchard's nodes (PIP joints).
Option 3: "Joint pain that worsens with activity and improves with rest" is also classic for Osteoarthritis. Mechanical stress on damaged cartilage worsens pain. In contrast, RA pain and stiffness are often worst after rest (morning) and improve with movement.
Option 4: "Localized joint inflammation affecting only weight-bearing joints" is more indicative of OA or traumatic arthritis. RA is systemic and commonly involves non-weight-bearing joints like the wrists, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints early in the disease process.
Related Concepts: Beyond joint symptoms, remember RA has extra-articular manifestations like rheumatoid nodules, vasculitis, pleuritis, pericarditis, and sicca syndrome (dry eyes/mouth). Laboratory findings often include a positive Rheumatoid Factor (RF) and Anti-Cyclic Citrullinated Peptide (anti-CCP) antibody, along with elevated inflammatory markers like Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP).
Worsens with activity/weight-bearing; improves with rest
No (localized)
Side-by-Side Comparison!
Feature
Rheumatoid Arthritis (RA)
Osteoarthritis (OA)
Nature
Systemic autoimmune disease
Localized degenerative disease
Joint Involvement
Symmetrical (both sides)
Asymmetrical (often one side)
Morning Stiffness
Prolonged (>30 min to hours)
Brief (
임상 시나리오
Nursing Clinical Practice GuideClinical Scenario: You are the day-shift nurse for Mrs. Johnson, a 52-year-old female with a 5-year history of RA. She is admitted for a flare-up. During your morning assessment, she states, "My hands are so stiff and swollen I can barely make a fist. It's always like this when I wake up. It takes me two hours just to get moving."
Nursing Intervention Strategy:
Assessment: Perform a thorough joint assessment. Palpate the MCP and PIP joints of both hands—note symmetrical, warm, boggy swelling. Assess her grip strength. Use a pain scale (0-10) to quantify her pain and stiffness. Assess for other systemic signs: fever, fatigue, rheumatoid nodules (check elbows), and dry eyes/mouth.
Nursing Diagnosis: Chronic Pain related to inflammatory process. Impaired Physical Mobility related to pain and joint deformity.
Planning & Implementation:
Medication Timing: Collaborate with the provider to schedule her morning dose of NSAID or corticosteroid 1-2 hours before she needs to be active. Administer on time.
Morning Care: Encourage a warm shower or paraffin wax bath in the morning to help loosen stiff joints. Assist with gentle range-of-motion (ROM) exercises after medication has taken effect.
Joint Protection: Teach principles: use largest/strongest joints for tasks (push doors with forearm, not fingers), avoid tight gripping, use adaptive devices (built-up utensil handles, jar openers).
Energy Conservation: Plan activities with rest periods. Prioritize tasks.
Evaluation: Re-assess pain and stiffness levels 1 hour after medication and activity. Monitor for improved ability to perform ADLs (Activities of Daily Living).
Patient Safety and Precautions:
Infection Risk: Clients on DMARDs (methotrexate) or biologics are immunosuppressed. Monitor for fever, sore throat, cough. Teach strict hand hygiene and avoidance of crowds when possible.
Medication Side Effects: Methotrexate can cause hepatotoxicity and bone marrow suppression. Monitor LFTs (Liver Function Tests) and CBC (Complete Blood Count). Teach to avoid alcohol. NSAIDs increase risk for GI bleeding and renal impairment.
Fall Risk: Impaired mobility and foot deformities increase fall risk. Ensure a clear path to the bathroom, proper footwear, and use of assistive devices if needed.
Nursing Procedure & Medication FlowAdministering Methotrexate (a common DMARD):
Assessment: Check latest CBC and LFT results before administration. Assess for signs of infection.
Education: Teach self-administration of weekly dose (often oral or SQ). Emphasize: "This is a weekly medication, not daily." Instruct to take folic acid supplement as prescribed to reduce side effects.
Monitoring: Schedule regular lab draws. Watch for mouth ulcers, unusual bruising/bleeding, yellowing of skin (jaundice).
A Word from Your Senior Nurse
"Remember, RA is more than just 'achy joints.' It's a whole-body disease that affects a person's identity, independence, and quality of life. Your empathy and your knowledge of how to manage their daily challenges—like that brutal morning stiffness—make a world of difference. When you see a question about 'morning stiffness >1 hour,' don't just think 'RA.' Think of Mrs. Johnson and how you would help her start her day. That connection between the textbook and the human being is what makes a great nurse. On the NCLEX, they're testing if you can make that connection too."
핵심 개념
Rheumatoid Arthritis — A chronic systemic autoimmune disorder characterized by bilateral symmetrical inflammation of the synovial membranes, leading to joint pain, swelling, stiffness, and potential deformity.
Synovitis — Inflammation of the synovial membrane lining the joint capsule. In RA, this is the primary site of autoimmune attack, causing swelling, warmth, and pain.
Disease-Modifying Antirheumatic Drugs — A class of medications (e.g., methotrexate) used in RA to slow or modify the disease process by suppressing the overactive immune system, rather than just treating symptoms.
Morning Stiffness — A hallmark symptom of inflammatory arthritis like RA. It refers to joint stiffness after periods of inactivity, typically lasting more than 30 minutes to several hours and improving with movement.
Osteoarthritis — A degenerative joint disease caused by the breakdown of articular cartilage, leading to pain, stiffness (brief morning stiffness), and bony enlargement. It is not systemic or autoimmune.
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