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A nurse in an outpatient clinic.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Osteoarthritis

Actions to take:

Instruct the client to apply topical analgesics

Instruct the client to apply heat and cold

Parameters to monitor

Joint deformities

ESR

Rationale:

  • Condition: 1. Osteoarthritis
    Rationale:

    • Gradual onset of joint pain over 2 years, affecting weight-bearing (knee) and commonly used joints (wrist). Crepitus noted in affected joints. No systemic symptoms (no rashes, no fever). ANA negative, ESR normal, uric acid mildly elevated but within normal limits, less consistent with gout or SLE. Family history is not strongly suggestive of autoimmune disease.

  • Nursing actions to take: 3. Instruct the client to apply topical analgesics, 5. Instruct the client to apply heat and cold
    Rationale:

    • Topical analgesics help relieve localized joint pain.

    • Heat and cold therapy help reduce pain and stiffness.

    • Dietary restrictions (purines) and vaccine precautions are not priorities for osteoarthritis.

  • Parameters to monitor: 1. Joint deformities, 4. ESR
    Rationale:

    • Joint deformities: Monitor progression of structural joint changes.

    • ESR: Although typically normal in OA, it can help distinguish from inflammatory arthritis if changes occur.


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Related Questions

Correct Answer is C

Explanation

A. Incorrect – Diminished breath sounds are not a primary sign of hemorrhage after a tonsillectomy.
B. Incorrect – Increased drowsiness could be due to pain medication or anesthesia effects, not necessarily hemorrhage.
C. Correct – Frequent swallowing is a classic sign of post-tonsillectomy bleeding because the child may be swallowing blood. The nurse should assess for bleeding immediately.
D. Incorrect – Elevated pain level is expected postoperatively but does not specifically indicate hemorrhage.

Correct Answer is C

Explanation

A. An inability to obey commands suggests a lower motor response score.
B. Withdrawal from pain is seen in clients with a lower GCS score (e.g., 4–6).
C. A GCS score of 15 (the highest possible score) indicates: Eye opening: Spontaneous (4 points), verbal response: Oriented (5 points), motor response: Obeys commands (6 points)
D. Opening eyes to sound is a GCS score of 3, not 15.

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