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A nurse is caring for a client in an outpatient clinic.

Exhibits

Complete the following sentence by using the lists of options. The client is at highest risk for developing

evidenced by the client's
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

  • Rheumatoid arthritis is the most likely condition given the client’s bilateral wrist and shoulder stiffness lasting for several hours in the morning, fatigue, and loss of appetite. The elevated ESR and anemia further support chronic inflammation. Positive ANA, while not specific, can be present in RA and other autoimmune disorders.
  • Osteoarthritis is incorrect because it typically presents with stiffness that improves within 30 minutes of activity, not lasting for several hours. It is also a non-inflammatory condition, whereas the client has elevated ESR and anemia, suggesting an inflammatory process.
  • Gout is unlikely as it usually causes acute, severe joint pain with redness and swelling, often affecting the big toe. The client’s uric acid level is within normal range, making gout less probable.
  • Carpal tunnel syndrome primarily causes numbness, tingling, and weakness in the hands due to median nerve compression. It does not typically cause prolonged morning stiffness, fatigue, or systemic inflammation.
  • Positive ANA is not the best choice because while it is seen in rheumatoid arthritis, it is also present in other autoimmune diseases such as lupus. It does not specifically confirm RA.
  • Normal WBC count does not support an inflammatory condition, as RA can lead to mild leukopenia, which is seen in the follow-up labs.
  • Low blood pressure is not a defining feature of RA and does not correlate with the client’s symptoms or disease progression


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Related Questions

Correct Answer is D

Explanation

A. Apply water-soluble lubricant to the site. Lubricants are not necessary for gastrostomy tube site care. Instead, the nurse should keep the area clean and dry to prevent irritation and infection. Applying lubricant could increase moisture, potentially leading to skin breakdown or fungal infections.
B. Attach an extension tube to the site's opening prior to use. Extension tubes are only needed for certain types of gastrostomy devices, such as low-profile buttons, and should be attached only when feeding or administering medications. Continuous attachment is unnecessary and may increase the risk of dislodgment or contamination.
C. Tape the tube to the child's cheek. Taping a gastrostomy tube to the cheek is inappropriate, as it does not provide adequate stabilization and may cause discomfort. This technique is more commonly used for securing nasogastric tubes rather than gastrostomy tubes.
D. Secure the tubing to the child's abdomen. Properly securing the gastrostomy tube to the abdomen helps prevent accidental dislodgment, irritation, and skin breakdown. The tube should be secured with tape or a securement device while allowing slight movement to reduce tension on the insertion site.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The preschooler is at risk for developing atelectasis evidenced by the preschooler's refusal to use the spirometer.

Atelectasis, or lung collapse, is a common postoperative complication due to shallow breathing and inadequate lung expansion. In this case the child refuses to use the incentive spirometer, which is crucial for preventing atelectasis by encouraging deep breathing. Shallow respirations are noted in both assessments, indicating reduced lung expansion.

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