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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 {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for Correct Options:

  1. Late decelerations on fetal heart rate (FHR) – First Priority

Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. This is the most urgent concern because prolonged fetal distress can lead to hypoxia and acidosis, increasing the risk of complications such as stillbirth or emergency cesarean birth. Nursing Actions: Reposition the client to left lateral position to improve placental perfusion. Administer oxygen at 10 L/min via a non-rebreather mask. Increase IV fluids to improve maternal circulation. Stop oxytocin if it's being used, as it may be causing excessive contractions. Notify the provider immediately for further interventions, such as potential intrauterine resuscitation or emergent delivery.

  1. Positive Group B streptococcus (GBS) status – Second Priority

The client tested positive for GBS, a bacterial infection that can be transmitted to the newborn during birth, leading to neonatal sepsis, pneumonia, or meningitis. While this is a significant concern, it is secondary to the immediate fetal distress from late decelerations. Nursing Actions: Administer IV antibiotics (penicillin G or an alternative) as ordered to prevent neonatal infection. Monitor for signs of infection in the newborn after delivery.

Rationale for Incorrect Options:

  • Severe back pain rated 10/10 – Pain management is important, but fetal distress takes precedence over maternal discomfort.
  • Restlessness and irritability – These could indicate maternal distress or labor progression, but they are not as urgent as fetal oxygenation.
  • Increasing contraction intensity and frequency – This is expected as labor progresses but is not immediately life-threatening.
  • Fatigue and emotional distress – While support is essential, it is not a priority over fetal well-being or preventing neonatal infection.

Correct Answer is C

Explanation

A. Encourage the family to be with the child during mealtimes. While having family present can provide support and create a positive mealtime atmosphere, it is not the first step in addressing poor dietary intake. Understanding the underlying reasons for the child's poor intake is more critical initially.
B. Instruct the family to praise the child when they eat. Encouraging praise can help create a positive association with eating, but this action is more effective after understanding the child's dietary habits and preferences.
C. Obtain the child's dietary history. Obtaining the child's dietary history is the most important first step. This allows the nurse to identify specific concerns, such as food preferences, patterns of intake, and any potential food allergies or intolerances. Understanding the child's current dietary habits is essential for developing an effective plan to improve nutritional intake.
D. Offer the child nutritious snacks between meals. Offering nutritious snacks can help increase caloric intake, but this should be done after assessing the child's dietary history to ensure that the snacks are appropriate and tailored to the child's needs and preferences.

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