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A nurse is caring for a client in a provider's office.

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 []

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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Provide a diet of fresh fruits and vegetables for the client: While a high-protein, high-calorie diet is essential for wound healing in burn patients, fresh fruits and vegetables may not be appropriate if the client is immunocompromised due to the risk of bacterial contamination. Cooked or peeled produce is often recommended.

B. Apply new gloves when alternating between wound care sites: Burn wounds are highly susceptible to infection. Changing gloves between different wound sites prevents cross-contamination and reduces the risk of spreading bacteria, which is critical in preventing wound infections and sepsis.

C. Clean the equipment in the client's room once per week: Equipment in a burn unit should be cleaned and disinfected daily to minimize the risk of infection. Weekly cleaning is insufficient for infection control in an immunocompromised client.

D. Limit visitation time for the client's children to 40 min per day: While infection control is a priority, limiting visitation is not typically necessary unless the visitors are ill. Emotional support from family can aid in psychological recovery, and proper infection control measures can be implemented without strict visitation limits.

A. Wound appearance B. Blood glucose C. WBC D. Urinary frequency E. Temperature F. Blood pressure G. Heart rate

Correct Answer is ["A","B"]

Explanation

Wound appearance: The client's wound is consistent in size (3 cm x 4 cm) but the purulent drainage may indicate ongoing infection. However, the key aspect is that the client has a scheduled appointment with a wound care specialist, which suggests that there is a plan in place for managing the wound, indicating that the situation is being monitored and potentially improving with treatment.
Blood glucose: The blood glucose level decreased from 250 mg/dL two weeks ago to 140 mg/dL today. While still elevated, this reduction indicates better glycemic control, which is essential for overall health and particularly important in the context of healing and managing diabetes.

WBC: The WBC count increased from 9,500/mm³ to 11,200/mm³. This increase could indicate an ongoing infection or inflammatory process, suggesting that the client's condition is not improving in this regard.
Urinary frequency: The information provided does not detail any changes in urinary frequency, and given the initial presentation of increased thirst and urination, ongoing monitoring is essential. Without additional context, this does not indicate improvement.
Temperature: The temperature increased from 38.3°C (100.9°F) to 39.0°C (102.2°F), indicating a worsening state that may suggest infection or systemic response rather than improvement.
Blood pressure: The blood pressure dropped from 98/74 mm Hg to 90/68 mm Hg, which is concerning and indicates potential hypotension, possibly due to infection or other factors affecting the client’s status.
Heart rate: The heart rate increased from 104/min to 106/min, suggesting that the client may be experiencing stress, pain, or infection, indicating that their condition may not be improving.

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A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include?

Correct Answer is B

Explanation

The nurse has reviewed the nurses' notes at 0940, vital signs at 0945, and laboratory reports at 1020. Select the 2 findings that indicate the client's condition is improving.

Correct Answer is ["A","B"]

Explanation

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