PNR 408 MEDICAL-SURGICAL NURSING FINAL EXAM 2026 |
Lewis Chapters 54,56,59,61,63 | Test 1 & 2 Cumulative | 100%
Correct Solved | Pass Guaranteed - A+ Graded
[Chapter 54: Nursing Management - Arthritis & Connective Tissue Diseases (Q1-15)]
1. A 72-year-old patient reports gradual onset of bilateral knee pain that worsens
with activity and improves with rest. Physical examination reveals bony
enlargements at the distal interphalangeal joints. Which nursing intervention is
most appropriate for initial pharmacologic management?
A. Initiate methotrexate 7.5 mg weekly and schedule CBC monitoring every 2 weeks.
B. Recommend celecoxib 200 mg daily and teach the patient to monitor for GI bleeding.
C. Advise acetaminophen 500 mg PO every 6 hours as needed, not exceeding 3,000 mg
daily. [CORRECT]
D. Arrange for intra-articular corticosteroid injection as first-line therapy for both knees.
Rationale: Acetaminophen is the first-line pharmacologic therapy for osteoarthritis per
ACR/AAOS guidelines due to its favorable safety profile; methotrexate is for RA,
celecoxib is second-line after acetaminophen failure, and intra-articular injections are
not first-line.
Correct Answer: C
2. A 48-year-old woman with newly diagnosed rheumatoid arthritis reports
symmetric swelling of the metacarpophalangeal and proximal interphalangeal
joints with morning stiffness lasting 90 minutes. Which finding requires
immediate follow-up before initiating etanercept?
A. History of hypertension controlled with lisinopril for 5 years.
B. Positive Quantiferon-TB Gold test indicating latent tuberculosis infection. [CORRECT]
C. Elevated anti-CCP antibodies with a titer of 1:320.
D. Bilateral wrist synovitis confirmed on musculoskeletal ultrasound.
,Rationale: TNF-alpha inhibitors like etanercept increase the risk of reactivating latent TB;
patients must be screened and treated for latent TB prior to initiation. Hypertension,
anti-CCP positivity, and synovitis are expected findings in RA and do not contraindicate
biologic therapy.
Correct Answer: B
3. A 58-year-old man presents with sudden onset of severe pain, erythema, and
swelling of the right first metatarsophalangeal joint. He admits to consuming red
meat and beer at a party last night. Which acute management strategy is most
appropriate?
A. Start allopurinol 100 mg daily and increase fluid intake to 3 liters per day.
B. Administer indomethacin 50 mg PO TID with food and colchicine 1.2 mg then 0.6 mg
1 hour later. [CORRECT]
C. Apply warm compresses to the affected joint and encourage weight-bearing exercise
once pain subsides.
D. Initiate pegloticase 8 mg IV every 2 weeks and monitor for infusion reactions.
Rationale: NSAIDs (indomethacin) and low-dose colchicine are first-line therapies for
acute gout flares; allopurinol and pegloticase are chronic urate-lowering therapies that
should not be started during acute attacks and may worsen flares. Warm compresses
and weight-bearing are contraindicated during acute gout.
Correct Answer: B
4. A patient taking methotrexate 15 mg weekly for rheumatoid arthritis develops
oral ulcers and mild alopecia. Which supplementation should the nurse
recommend to reduce these adverse effects?
A. Vitamin B12 1,000 mcg intramuscularly monthly.
B. Folic acid 1 mg daily except on the day of methotrexate dosing. [CORRECT]
C. Iron sulfate 325 mg daily with vitamin C.
D. Calcium carbonate 1,200 mg daily with vitamin D.
Rationale: Folic acid supplementation reduces methotrexate toxicity including
stomatitis, GI upset, and hepatotoxicity; it is typically taken daily except the
methotrexate dose day. B12, iron, and calcium do not mitigate methotrexate adverse
effects.
Correct Answer: B
, 5. The nurse is reviewing charts for four patients with arthritis. Which clinical
presentation is most consistent with osteoarthritis rather than rheumatoid
arthritis?
A. Symmetric joint involvement of the wrists and metacarpophalangeal joints with
prolonged morning stiffness.
B. Asymmetric degeneration of the distal interphalangeal joints with bony nodules and
pain that worsens with weight-bearing activity. [CORRECT]
C. Systemic symptoms including low-grade fever, fatigue, and rheumatoid nodules over
the extensor surfaces.
D. Elevated erythrocyte sedimentation rate and C-reactive protein with positive
rheumatoid factor.
Rationale: OA is characterized by asymmetric involvement of weight-bearing joints and
distal interphalangeal bony nodes (Heberden's); RA presents with symmetric small joint
inflammation, systemic symptoms, positive RF/anti-CCP, and elevated inflammatory
markers.
Correct Answer: B
6. A patient with rheumatoid arthritis is experiencing an acute flare with significant
fatigue and joint pain. Which nursing intervention best promotes energy
conservation?
A. Encourage the patient to complete all morning hygiene activities before resting.
B. Schedule physical therapy sessions in the afternoon after morning stiffness resolves.
C. Teach the patient to alternate periods of activity with planned rest periods throughout
the day. [CORRECT]
D. Advise the patient to perform all joint range-of-motion exercises in one continuous
45-minute session.
Rationale: Energy conservation for RA involves pacing activities, alternating rest with
activity, and prioritizing essential tasks during times of peak energy; continuous exertion
without rest exacerbates fatigue and inflammation.
Correct Answer: C
7. A patient with recurrent gout attacks asks which foods to limit. Which dietary
recommendation is most accurate?
, A. Increase intake of organ meats, anchovies, and shellfish to boost iron stores.
B. Limit purine-rich foods including red meat, seafood, and alcohol, especially beer.
[CORRECT]
C. Consume high-fructose corn syrup beverages to maintain adequate caloric intake.
D. Eliminate all dairy products to reduce saturated fat consumption.
Rationale: Purine-rich foods (red meat, organ meats, certain seafood) and alcohol
(particularly beer) increase uric acid production and trigger gout flares; high-fructose
corn syrup also raises uric acid. Low-fat dairy products may actually reduce gout risk.
Correct Answer: B
8. During a routine follow-up, a patient with long-standing rheumatoid arthritis
reports dry eyes and dry mouth. The nurse recognizes these symptoms as
indicative of which associated condition?
A. Felty's syndrome.
B. Sjögren's syndrome. [CORRECT]
C. Systemic lupus erythematosus.
D. Polymyalgia rheumatica.
Rationale: Secondary Sjögren's syndrome is a common extra-articular manifestation of
RA characterized by lymphocytic infiltration of exocrine glands causing xerophthalmia
and xerostomia; Felty's syndrome involves neutropenia and splenomegaly.
Correct Answer: B
9. A 68-year-old patient with end-stage osteoarthritis of the right hip has failed
conservative management including acetaminophen, NSAIDs, physical therapy,
and intra-articular injections. Which intervention represents the next standard of
care?
A. Total hip arthroplasty. [CORRECT]
B. Arthroscopic debridement and lavage.
C. Long-term opioid therapy with oxycodone 5 mg every 4 hours.
D. Bilateral hip fusion to prevent future contralateral degeneration.
Rationale: Total joint arthroplasty is the definitive surgical treatment for end-stage OA
when conservative measures fail; arthroscopic lavage lacks evidence for OA, long-term
opioids are not standard due to risks, and hip fusion severely limits mobility.
Correct Answer: A
Lewis Chapters 54,56,59,61,63 | Test 1 & 2 Cumulative | 100%
Correct Solved | Pass Guaranteed - A+ Graded
[Chapter 54: Nursing Management - Arthritis & Connective Tissue Diseases (Q1-15)]
1. A 72-year-old patient reports gradual onset of bilateral knee pain that worsens
with activity and improves with rest. Physical examination reveals bony
enlargements at the distal interphalangeal joints. Which nursing intervention is
most appropriate for initial pharmacologic management?
A. Initiate methotrexate 7.5 mg weekly and schedule CBC monitoring every 2 weeks.
B. Recommend celecoxib 200 mg daily and teach the patient to monitor for GI bleeding.
C. Advise acetaminophen 500 mg PO every 6 hours as needed, not exceeding 3,000 mg
daily. [CORRECT]
D. Arrange for intra-articular corticosteroid injection as first-line therapy for both knees.
Rationale: Acetaminophen is the first-line pharmacologic therapy for osteoarthritis per
ACR/AAOS guidelines due to its favorable safety profile; methotrexate is for RA,
celecoxib is second-line after acetaminophen failure, and intra-articular injections are
not first-line.
Correct Answer: C
2. A 48-year-old woman with newly diagnosed rheumatoid arthritis reports
symmetric swelling of the metacarpophalangeal and proximal interphalangeal
joints with morning stiffness lasting 90 minutes. Which finding requires
immediate follow-up before initiating etanercept?
A. History of hypertension controlled with lisinopril for 5 years.
B. Positive Quantiferon-TB Gold test indicating latent tuberculosis infection. [CORRECT]
C. Elevated anti-CCP antibodies with a titer of 1:320.
D. Bilateral wrist synovitis confirmed on musculoskeletal ultrasound.
,Rationale: TNF-alpha inhibitors like etanercept increase the risk of reactivating latent TB;
patients must be screened and treated for latent TB prior to initiation. Hypertension,
anti-CCP positivity, and synovitis are expected findings in RA and do not contraindicate
biologic therapy.
Correct Answer: B
3. A 58-year-old man presents with sudden onset of severe pain, erythema, and
swelling of the right first metatarsophalangeal joint. He admits to consuming red
meat and beer at a party last night. Which acute management strategy is most
appropriate?
A. Start allopurinol 100 mg daily and increase fluid intake to 3 liters per day.
B. Administer indomethacin 50 mg PO TID with food and colchicine 1.2 mg then 0.6 mg
1 hour later. [CORRECT]
C. Apply warm compresses to the affected joint and encourage weight-bearing exercise
once pain subsides.
D. Initiate pegloticase 8 mg IV every 2 weeks and monitor for infusion reactions.
Rationale: NSAIDs (indomethacin) and low-dose colchicine are first-line therapies for
acute gout flares; allopurinol and pegloticase are chronic urate-lowering therapies that
should not be started during acute attacks and may worsen flares. Warm compresses
and weight-bearing are contraindicated during acute gout.
Correct Answer: B
4. A patient taking methotrexate 15 mg weekly for rheumatoid arthritis develops
oral ulcers and mild alopecia. Which supplementation should the nurse
recommend to reduce these adverse effects?
A. Vitamin B12 1,000 mcg intramuscularly monthly.
B. Folic acid 1 mg daily except on the day of methotrexate dosing. [CORRECT]
C. Iron sulfate 325 mg daily with vitamin C.
D. Calcium carbonate 1,200 mg daily with vitamin D.
Rationale: Folic acid supplementation reduces methotrexate toxicity including
stomatitis, GI upset, and hepatotoxicity; it is typically taken daily except the
methotrexate dose day. B12, iron, and calcium do not mitigate methotrexate adverse
effects.
Correct Answer: B
, 5. The nurse is reviewing charts for four patients with arthritis. Which clinical
presentation is most consistent with osteoarthritis rather than rheumatoid
arthritis?
A. Symmetric joint involvement of the wrists and metacarpophalangeal joints with
prolonged morning stiffness.
B. Asymmetric degeneration of the distal interphalangeal joints with bony nodules and
pain that worsens with weight-bearing activity. [CORRECT]
C. Systemic symptoms including low-grade fever, fatigue, and rheumatoid nodules over
the extensor surfaces.
D. Elevated erythrocyte sedimentation rate and C-reactive protein with positive
rheumatoid factor.
Rationale: OA is characterized by asymmetric involvement of weight-bearing joints and
distal interphalangeal bony nodes (Heberden's); RA presents with symmetric small joint
inflammation, systemic symptoms, positive RF/anti-CCP, and elevated inflammatory
markers.
Correct Answer: B
6. A patient with rheumatoid arthritis is experiencing an acute flare with significant
fatigue and joint pain. Which nursing intervention best promotes energy
conservation?
A. Encourage the patient to complete all morning hygiene activities before resting.
B. Schedule physical therapy sessions in the afternoon after morning stiffness resolves.
C. Teach the patient to alternate periods of activity with planned rest periods throughout
the day. [CORRECT]
D. Advise the patient to perform all joint range-of-motion exercises in one continuous
45-minute session.
Rationale: Energy conservation for RA involves pacing activities, alternating rest with
activity, and prioritizing essential tasks during times of peak energy; continuous exertion
without rest exacerbates fatigue and inflammation.
Correct Answer: C
7. A patient with recurrent gout attacks asks which foods to limit. Which dietary
recommendation is most accurate?
, A. Increase intake of organ meats, anchovies, and shellfish to boost iron stores.
B. Limit purine-rich foods including red meat, seafood, and alcohol, especially beer.
[CORRECT]
C. Consume high-fructose corn syrup beverages to maintain adequate caloric intake.
D. Eliminate all dairy products to reduce saturated fat consumption.
Rationale: Purine-rich foods (red meat, organ meats, certain seafood) and alcohol
(particularly beer) increase uric acid production and trigger gout flares; high-fructose
corn syrup also raises uric acid. Low-fat dairy products may actually reduce gout risk.
Correct Answer: B
8. During a routine follow-up, a patient with long-standing rheumatoid arthritis
reports dry eyes and dry mouth. The nurse recognizes these symptoms as
indicative of which associated condition?
A. Felty's syndrome.
B. Sjögren's syndrome. [CORRECT]
C. Systemic lupus erythematosus.
D. Polymyalgia rheumatica.
Rationale: Secondary Sjögren's syndrome is a common extra-articular manifestation of
RA characterized by lymphocytic infiltration of exocrine glands causing xerophthalmia
and xerostomia; Felty's syndrome involves neutropenia and splenomegaly.
Correct Answer: B
9. A 68-year-old patient with end-stage osteoarthritis of the right hip has failed
conservative management including acetaminophen, NSAIDs, physical therapy,
and intra-articular injections. Which intervention represents the next standard of
care?
A. Total hip arthroplasty. [CORRECT]
B. Arthroscopic debridement and lavage.
C. Long-term opioid therapy with oxycodone 5 mg every 4 hours.
D. Bilateral hip fusion to prevent future contralateral degeneration.
Rationale: Total joint arthroplasty is the definitive surgical treatment for end-stage OA
when conservative measures fail; arthroscopic lavage lacks evidence for OA, long-term
opioids are not standard due to risks, and hip fusion severely limits mobility.
Correct Answer: A
