A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)
Tight skin
Edema
Tophi
Symmetrical joint pain
Erythema
Correct Answer : B,C,E
A nurse collecting data from a client who has an exacerbation of gout should expect to find edema, tophi, and erythema. Gout is a type of arthritis that occurs when urate crystals accumulate in the joints, causing inflammation and intense pain. Edema (swelling) is a common symptom of gout⁴. Tophi are deposits of urate crystals that can form under the skin in people with chronic gout³. Erythema (redness) is another common symptom of gout⁴.
a. Tight skin is not a common symptom of gout.
d. Symmetrical joint pain is not a common symptom of gout, as it usually affects only one joint at a time.
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Correct Answer is C
Explanation
To prevent autonomic dysreflexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreflexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full¹.
Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreflexia.
Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreflexia.
Elevating the client's head is important but not an intervention to prevent autonomic dysreflexia.
Correct Answer is D
Explanation
Having the client lie prone several times each day is an appropriate nursing intervention for a client who is 2 days postoperative following an above-the-knee amputation. Lying prone can help prevent hip flexion contractures, which can occur after an above-the-knee amputation².
Elevating the foot of the bed is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.
Encouraging sitting up as much as possible is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.
Elevating the stump on a pillow is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.
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