A nurse is assisting in the care of a client who has tuberculosis. Which of the following personal protective equipment should the nurse wear during routine care for this client?

Neonatal hyperbilirubinemia occurs when there is an excess buildup of bilirubin due to increased red blood cell breakdown and immature liver conjugation. Phototherapy is used to convert bilirubin into water-soluble isomers that can be excreted through urine and stool. Effective treatment requires maximizing skin exposure to light and ensuring even distribution of phototherapy. Nursing care focuses on hydration, thermoregulation, eye protection, and frequent repositioning.

Rationale:
A. Applying lotion to the newborn’s skin every 2 hours is contraindicated during phototherapy because it can increase skin absorption of heat and potentially interfere with light penetration. Lotions and oils may also cause overheating or skin irritation when exposed to phototherapy lights. Skin should remain clean and dry to allow effective bilirubin breakdown.

B. Obtaining a blood glucose level every 4 hours is not a routine requirement for newborns receiving phototherapy unless there is a specific risk factor for hypoglycemia. Phototherapy primarily affects bilirubin metabolism and fluid balance rather than glucose regulation. Monitoring should focus on bilirubin levels, hydration status, and temperature.

C. Repositioning the newborn every 2 to 3 hours is appropriate because it ensures maximum skin exposure to phototherapy light. Changing the infant’s position helps expose different body surfaces, improving the effectiveness of bilirubin breakdown. This intervention also promotes even treatment and prevents pressure-related complications.

D. Offering glucose water every 1 to 2 hours is not recommended because it can interfere with adequate nutritional intake and is not effective in treating hyperbilirubinemia. Breast milk or formula feeding is preferred to promote bowel movements and bilirubin excretion. Frequent feeding helps reduce enterohepatic circulation of bilirubin more effectively than glucose water.

The most likely inflammatory joint disorder based on progressive bilateral joint stiffness, morning stiffness lasting several hours, fatigue, and positive autoimmune markers is rheumatoid arthritis. Rheumatoid arthritis is a chronic autoimmune disease characterized by symmetrical joint inflammation, elevated inflammatory markers, and systemic symptoms such as fatigue and anorexia. Differentiating it from other musculoskeletal conditions like gout, osteoarthritis, and fibromyalgia requires analysis of laboratory trends and clinical presentation. Elevated ESR and positive ANA support an autoimmune inflammatory process.

Rationale for Correct choices:

• Rheumatoid arthritis is an autoimmune disorder that typically presents with bilateral, symmetrical joint pain and stiffness, especially in the wrists and shoulders. Morning stiffness lasting hours and systemic symptoms such as fatigue and loss of appetite are classic features. The chronic progression over 6 months and involvement of multiple joints supports an inflammatory autoimmune condition rather than degenerative or metabolic causes. Positive ANA further supports an autoimmune etiology consistent with rheumatoid arthritis.

• Erythrocyte sedimentation rate (ESR) is a key marker of systemic inflammation and is commonly elevated in rheumatoid arthritis. The client’s ESR is persistently elevated above normal (21–22 mm/hr), indicating ongoing inflammatory activity. This supports disease progression and correlates with symptom worsening over time. Elevated ESR is more consistent with autoimmune inflammatory arthritis than metabolic or degenerative joint disease.

Rationales for incorrect choices:

• Fibromyalgia causes widespread musculoskeletal pain and fatigue but does not produce inflammatory markers such as elevated ESR or positive ANA. It is not associated with joint stiffness that worsens structurally over time or laboratory evidence of systemic inflammation. The client’s lab findings and autoimmune indicator make fibromyalgia less consistent with the presentation.

• Gout is caused by uric acid crystal deposition and typically presents as acute, episodic, severe joint pain, often in a single joint like the big toe. Although uric acid is within normal range here, the client’s symptoms are bilateral and chronic rather than episodic and inflammatory flare-based. This pattern does not align with gout pathophysiology.

• Osteoarthritis is a degenerative joint disease characterized by pain that worsens with activity and improves with rest, not prolonged morning stiffness lasting hours. It is also not associated with systemic inflammatory markers like ESR elevation or positive ANA. The bilateral stiffness with fatigue and autoimmune lab findings makes OA less likely.

• Although family history can increase susceptibility to autoimmune and musculoskeletal conditions, it is not a direct diagnostic indicator of disease activity in this client. It represents a risk factor rather than current evidence of active pathology. The client’s presentation and lab findings are more useful for diagnosis than hereditary background alone. Therefore, it is not the best evidence for current risk assessment.

• Diuretics are associated with increased risk of gout due to reduced uric acid excretion. However, the client’s uric acid levels are within normal range, and symptoms are not consistent with acute gout (which typically involves sudden, severe monoarticular pain, often in the big toe). The presentation is bilateral and chronic, not episodic or metabolic.

• Uric acid levels are used to evaluate gout, which presents with acute joint inflammation, typically in a single joint. This client’s uric acid is within normal limits and does not explain bilateral wrist and shoulder stiffness. Additionally, gout does not cause prolonged morning stiffness or positive ANA results. Therefore, uric acid is not the best indicator of the client’s condition.