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A nurse in an outpatient clinic is assisting with the care of a client.

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 is a degenerative joint disease characterized by progressive cartilage deterioration, leading to pain, stiffness, and crepitus in affected joints. The client’s symptoms of localized pain in the right knee and left wrist, along with crepitus, are hallmark features of osteoarthritis. The absence of systemic symptoms, such as fever or fatigue, further supports this diagnosis. Additionally, the client’s age and lack of widespread joint involvement are consistent with osteoarthritis rather than an inflammatory condition.

Actions to Take:

Instruct the client to apply heat. Heat application helps relieve pain and stiffness in osteoarthritis by increasing blood flow, relaxing muscles, and reducing joint discomfort. This is particularly useful for chronic joint conditions where stiffness worsens with inactivity.
Instruct the client to avoid foods high in purines. Although osteoarthritis itself is not directly related to uric acid levels, the client’s elevated uric acid suggests a risk for gouty arthritis. Avoiding purine-rich foods such as red meat, seafood, and alcohol can help prevent the development of gout, which could worsen joint symptoms.

Parameters to Monitor:

Monitoring mobility is essential in osteoarthritis as it progressively worsens over time. Assessing range of motion, stiffness, and functional limitations helps guide treatment adjustments and determine whether additional interventions, such as physical therapy or assistive devices, are necessary.
Uric acid level. The client’s uric acid level is elevated, which may indicate a predisposition to gout. Monitoring uric acid levels is important to prevent or identify early signs of gouty arthritis, which can coexist with osteoarthritis and cause episodic joint pain.

Rationale for Incorrect Options:

Rheumatoid Arthritis is an autoimmune disorder that typically presents with symmetrical joint involvement, morning stiffness lasting more than 30 minutes, and systemic symptoms such as fatigue and weight loss. The client does not exhibit these features, and their negative antinuclear antibodies (ANA) and normal erythrocyte sedimentation rate (ESR) make rheumatoid arthritis unlikely.
Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disorder that can cause joint pain along with systemic symptoms such as facial rashes, kidney involvement, and hematologic abnormalities. The client does not have the characteristic malar rash, widespread joint pain, or other systemic findings. Furthermore, their ANA is negative, which significantly reduces the likelihood of SLE.
Instruct the client to avoid large crowds is not appropriate because osteoarthritis is not an autoimmune or immunosuppressive condition. Unlike rheumatoid arthritis or lupus, osteoarthritis does not increase infection risk, so there is no need to avoid crowded places.
Instruct the client to apply cold would not be the preferred intervention for osteoarthritis. Cold therapy is generally more effective for acute inflammation, whereas heat is better for chronic joint pain and stiffness.
Lymphadenopathy is not a concern in osteoarthritis because it is a degenerative joint disease rather than an infectious or inflammatory condition. Swollen lymph nodes are more commonly seen in infections or autoimmune diseases like lupus.
ANA does not need to be monitored for osteoarthritis, as it is primarily used to diagnose autoimmune conditions such as lupus. The client’s ANA is already negative, further confirming that autoimmune disease is unlikely.

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Correct Answer is B

Explanation

A. New onset of hearing loss. Gentamicin is an aminoglycoside antibiotic known for its ototoxic effects, which can lead to irreversible hearing loss or vestibular dysfunction. The drug damages the hair cells in the inner ear, resulting in symptoms like tinnitus, dizziness, or difficulty hearing. Clients receiving gentamicin should be closely monitored for auditory changes, as early detection can help prevent worsening damage.
B. Constipation. Gentamicin does not typically affect gastrointestinal motility, making constipation an unlikely adverse effect. It primarily causes nephrotoxicity and ototoxicity, with its main targets being the kidneys and inner ear. Gastrointestinal side effects are rare and usually limited to nausea or mild discomfort rather than significant bowel irregularities.
C. Slurred speech. While aminoglycosides can cause neuromuscular blockade in rare cases, slurred speech is not a common adverse effect. More frequently, gentamicin affects the vestibular system, leading to balance disturbances or dizziness rather than impairing speech function. If neuromuscular symptoms develop, the medication should be reassessed to prevent severe complications.
D. Hypotension. Gentamicin does not directly cause hypotension as a primary side effect. Its adverse effects are more commonly associated with kidney damage, ototoxicity, and, in rare cases, neuromuscular paralysis. If a client on gentamicin experiences hypotension, other underlying causes such as sepsis or volume depletion should be considered.

A. Offer the client several choices at mealtimes. B. Alternate daily caregivers. C. Remind the client of the day and time often. D. Avoid discussing the client's fears.

Correct Answer is C

Explanation

A. Offer the client several choices at mealtimes. Clients with delirium often experience confusion and difficulty processing information. Providing too many choices can increase anxiety and agitation. Instead, offering simple and limited options helps reduce cognitive overload.
B. Alternate daily caregivers. Consistency in caregivers is important for clients with delirium to minimize confusion and distress. Frequent changes in caregivers can contribute to disorientation and make it more difficult for the client to feel secure.
C. Remind the client of the day and time often. Delirium is characterized by fluctuating levels of consciousness and confusion. Frequent orientation to time, place, and situation helps reduce anxiety and supports cognitive function. Using clocks, calendars, and familiar objects in the environment can reinforce orientation.
D. Avoid discussing the client's fears. Clients with delirium may have distressing thoughts or fears that should be acknowledged and addressed. Providing reassurance and a calm, supportive environment can help alleviate anxiety and improve the client's well-being.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

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