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A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?

Perform ADLs for the client to promote rest

Allow for frequent rest periods throughout the day

Use heat to reduce joint inflammation

Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain

Answer and Explanation

The Correct Answer is B

Allow for frequent rest periods throughout the day.

A. Perform ADLs for the client to promote rest. This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
B. Allow for frequent rest periods throughout the day. This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
C. Use heat to reduce joint inflammation. This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain. - D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.

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Correct Answer is B

Explanation

Choice A rationale:

Shellfish allergies are not a contraindication to receiving the influenza vaccine. The vaccine contains no shellfish-derived ingredients.

Choice B rationale:

Egg allergies are a contraindication to receiving the influenza vaccine. Traditionally, most influenza vaccines are prepared using eggs and can provoke allergic reactions in individuals allergic to eggs. However, individuals with a mild egg allergy can often receive the vaccine under medical supervision. It is crucial to assess the severity of the egg allergy and consult with an allergist or immunologist before administering the vaccine.

Choice C rationale:

Gelatin allergies are generally not a contraindication to receiving the influenza vaccine. While some vaccines contain gelatin, it is not a component of all influenza vaccines. If the specific vaccine being administered contains gelatin, it should be avoided in individuals with a gelatin allergy.

Choice D rationale:

Milk allergies are not a contraindication to receiving the influenza vaccine. Milk or dairy products are not typically included in the influenza vaccine formulation.

A. Weight B. Neuro status C. Auditory hallucinations D. Speech E. Restlessness

Correct Answer is ["B","C","E"]

Explanation

The correct answer is B, C, and E.

A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.

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A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?

Nursing Test Bank

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