A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?
Fatigue related to disease exacerbation.
Pain related to joint inflammation
Impaired physical mobility related to joint pain.
Self-care deficit related to disease progression.
The Correct Answer is B
A. This is a valid nursing problem and directly related to the client's condition. However, while fatigue is a significant concern, it is often a symptom of other underlying issues.
B. This is the highest priority nursing problem. Pain is a primary symptom of acute RA exacerbation and significantly impacts the client's quality of life, mobility, and overall well-being. Addressing pain is crucial for immediate comfort and to facilitate other interventions.
C. This is also a valid nursing problem, directly linked to the client's symptoms. However, it is a consequence of the pain, not the primary issue. Addressing the pain will improve mobility.
D. This is a potential long-term concern but not the highest priority at this acute stage. The client's immediate needs related to pain and mobility are more pressing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While fatigue can contribute to decreased appetite, it is not as directly linked to the specific condition of trigeminal neuralgia.
B. Trigeminal neuralgia is characterized by severe, sharp facial pain, often triggered by chewing, talking, or even a gentle breeze. This pain would significantly deter a person from eating, leading to imbalanced nutrition.
C. Nausea is not a typical symptom of trigeminal neuralgia and would not be the primary cause of imbalanced nutrition in this case.
D. While altered taste can affect food enjoyment, it is less likely to completely deter someone from eating compared to the intense pain associated with trigeminal neuralgia.
Correct Answer is B
Explanation
A. Hematocrit measures the proportion of blood volume that is occupied by red blood cells. A hematocrit of 33% is lower than the normal range (42% to 52% for males and 37% to 47% for females). While this indicates anemia and reduced oxygen-carrying capacity of the blood, it is not directly related to the risk for infection.
B. White blood cells (WBCs) are crucial for the immune system and fighting infections. A WBC count of 1,500/mm³ is significantly below the normal range (5,000 to 10,000/mm³). This low WBC count, also known as leukopenia, indicates a decreased ability to fight infections, making the client highly susceptible to infections.
C. Hemoglobin measures the oxygen-carrying capacity of red blood cells. A hemoglobin level of 10 g/dL is below the normal range (14 to 18 g/dL), indicating anemia. While anemia affects overall health and can contribute to fatigue and weakness, it does not directly indicate the risk for infection.
D. The red blood cell (RBC) count measures the number of red blood cells in the blood. A count of 3.5 x 10^12/L is below the normal range (4.2 to 5.4 x 10^12/L), indicating a reduction in red blood cells and anemia. Like low hemoglobin, this value indicates anemia but does not directly reflect the risk for infection.
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