A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

Confirmation of the autoimmune disease process.

Evidence of spread of the disease to the kidneys.

Indication of the onset of joint degeneration.

Representative of a decline in the client’s condition.

Answer and Explanation

The Correct Answer is A

Choice A reason: Rheumatoid factor is an antibody that is produced by the immune system and can bind to normal tissues, causing inflammation and damage. Rheumatoid factor is a marker of the autoimmune disease process that underlies rheumatoid arthritis, which is a chronic condition that affects the joints and other organs. A high level of rheumatoid factor can confirm the diagnosis of rheumatoid arthritis and indicate the severity of the disease.

Choice B reason: Rheumatoid factor is not a specific indicator of kidney involvement in rheumatoid arthritis, which is a rare but possible complication of the disease. Kidney damage can occur due to inflammation of the blood vessels, medication side effects, or dehydration. Kidney function can be assessed by other laboratory tests, such as blood urea nitrogen, creatinine, and urine analysis.

Choice C reason: Rheumatoid factor is not a direct cause of joint degeneration in rheumatoid arthritis, which is a progressive condition that leads to joint deformity and disability. Joint degeneration can occur due to chronic inflammation, erosion of cartilage and bone, and formation of nodules and cysts. Joint damage can be evaluated by physical examination, x-rays, and magnetic resonance imaging.

Choice D reason: Rheumatoid factor is not a reliable predictor of the client’s condition in rheumatoid arthritis, which is a variable and unpredictable disease that can have periods of remission and exacerbation. The client’s condition can be influenced by many factors, such as age, gender, genetics, lifestyle, and treatment. The client’s condition can be monitored by clinical symptoms, functional status, and quality of life.

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Correct Answer is B

Explanation

Choice A reason: Log rolling the client and placing adult disposable briefs beneath the client is not a correct intervention, as it can cause displacement or misalignment of the fracture, which can lead to complications, such as delayed healing, nerve damage, or infection. Log rolling is a technique that involves moving the client as a unit, without twisting or bending the spine. Adult disposable briefs are absorbent pads that can be worn to manage urinary incontinence.

Choice B reason: Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.

Choice C reason: Releasing the traction so the client can use a bedpan is not a correct intervention, as it can compromise the fracture reduction and alignment, and cause pain and discomfort to the client. A bedpan is a shallow vessel that can be used to collect urine or feces from the client, by placing it under the client's buttocks. Releasing the traction can also increase the risk of bleeding, swelling, or infection.

Choice D reason: Inserting an indwelling urinary catheter preoperatively is not a necessary intervention, unless the client has urinary retention, obstruction, or infection. An indwelling urinary catheter is a tube that is inserted into the bladder through the urethra, and attached to a drainage bag. An indwelling urinary catheter can pose risks of trauma, infection, or bladder spasms, and should be avoided unless indicated.

A. Apical heart rate of 100 to 110 beats/minute. B. Redness and edema noted at the incision site. C. High-pitched sound heard upon inspiration. D. Pain rating of 8 on a scale of 1 to 10.

Correct Answer is C

Explanation

Choice A reason: An apical heart rate of 100 to 110 beats/minute is not unusual after surgery, as the client may be experiencing stress, pain, or anxiety. This finding does not require immediate action by the nurse, but should be monitored and reported if it persists or worsens.

Choice B reason: Redness and edema at the incision site are expected signs of inflammation and healing after surgery. This finding does not require immediate action by the nurse, but should be assessed for signs of infection, such as pus, warmth, or foul odor.

Choice C reason: A high-pitched sound heard upon inspiration, also known as stridor, is a sign of upper airway obstruction, which can be life-threatening. This finding requires immediate action by the nurse, such as administering oxygen, suctioning, or calling for help.

Choice D reason: A pain rating of 8 on a scale of 1 to 10 indicates severe pain, which can affect the client's recovery and comfort. This finding requires prompt action by the nurse, such as administering analgesics, repositioning, or providing non-pharmacological interventions. However, this is not as urgent as choice C, which involves the client's airway.

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A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

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