A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?

A. Position the client with the head of the bed elevated to a 15° angle: Clients with pericarditis typically experience relief when sitting up and leaning forward, as this reduces pressure on the inflamed pericardium. A 15° elevation is too low to provide significant relief.

B. Check the client for jugular venous flattening: Pericarditis, especially when complicated by cardiac tamponade, leads to jugular venous distension rather than flattening due to impaired venous return to the heart.

C. Administer an anticoagulant medication to the client: Anticoagulants are not routinely used in pericarditis because they may increase the risk of hemorrhagic pericardial effusion, particularly if pericarditis is due to an inflammatory or infectious cause.

D. Assess the client for a paradoxical blood pressure: Pulsus paradoxus, a significant drop in systolic blood pressure during inspiration, is a key sign of cardiac tamponade, a life-threatening complication of pericarditis. Monitoring for this helps in early detection and management.

Condition:

• Rheumatoid arthritis

Actions to Take:

• Assess joints for warmth and redness.
• Assess for paresthesias.

Parameters to Monitor:

• Weight-bearing joints.
• Decreased immunity.

Rationale:

Condition Choices

• Osteoporosis: Osteoporosis primarily leads to bone demineralization and increased fracture risk rather than inflammatory joint pain, swelling, and systemic symptoms such as fever and fatigue. The client’s symptoms, including joint inflammation and subcutaneous nodules, are not characteristic of osteoporosis.
• Osteoarthritis: Osteoarthritis typically presents with asymmetric joint involvement, stiffness that worsens with activity, and crepitus in weight-bearing joints. The client’s symptoms, including symmetric joint swelling, prolonged morning stiffness, and systemic inflammation markers, are more consistent with an autoimmune disorder like rheumatoid arthritis.
• Rheumatoid arthritis: The presence of bilateral joint pain, stiffness, swelling, subcutaneous nodules, and elevated inflammatory markers (ESR and CRP) strongly suggests rheumatoid arthritis. The morning stiffness, systemic symptoms like fatigue and low-grade fever, and the impact on mobility further support this diagnosis.
• Gout: Gout is characterized by acute, episodic joint pain, typically affecting the metatarsophalangeal joint of the big toe. The client’s symptoms are more widespread and chronic, involving multiple joints and systemic inflammation, which is not typical of gout.

Actions to Take

• Assess joints for warmth and redness: Inflammation in rheumatoid arthritis leads to synovial swelling, warmth, and redness. Regular assessment helps track disease progression and the effectiveness of treatment.
• Assess for paresthesias: Chronic inflammation and joint deformities in rheumatoid arthritis can lead to nerve compression, resulting in numbness or tingling, particularly in the hands and feet.
• Assess for crepitus in weight-bearing joints: Crepitus is more commonly associated with osteoarthritis due to cartilage degeneration. While rheumatoid arthritis affects weight-bearing joints, it does so through inflammatory destruction rather than mechanical wear.
• Recommend the client spend at least 5 min outside in the sun daily: Sun exposure can help with vitamin D synthesis, but rheumatoid arthritis is not primarily related to vitamin D deficiency. This intervention is more relevant for osteoporosis management.

Parameters to Monitor

• Weight-bearing joints: Rheumatoid arthritis commonly affects the knees, hips, and other weight-bearing joints, contributing to mobility issues and falls. Monitoring joint involvement helps assess disease progression.
• Decreased immunity: Rheumatoid arthritis and its treatments, such as immunosuppressive medications, increase the risk of infections. Monitoring for signs of immunosuppression is essential for early intervention.
• Joint inflammation in the big toe: This is more indicative of gout, which presents with acute episodes of pain and swelling in the first metatarsophalangeal joint rather than the widespread, chronic inflammation seen in rheumatoid arthritis.
• Calcium and vitamin D levels: While important for bone health, these levels do not provide direct insight into rheumatoid arthritis progression. They are more relevant in osteoporosis management.
• Cervical neck pain: While rheumatoid arthritis can affect the cervical spine, particularly at the atlantoaxial joint, the primary concern is peripheral joint inflammation and systemic symptoms rather than isolated neck pain.