A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?
Encourage the client to take a cool sponge bath each morning.
Administer opioid analgesia.
Increase the client's dietary iron intake.
Restrict the client's intake of foods high in purines.
The Correct Answer is C
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate⁴.
To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse³⁵.
In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.
Correct Answer is C
Explanation
A. Saying "I'm sure your family does not want you to die" is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's assumption on the client. This option is incorrect.
B. Asking "Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, and may make the client feel defensive or ashamed. This option is incorrect.
C. Asking "How does this make you feel?" is a therapeutic response, as it encourages the client to express their emotions and shows empathy and interest from the nurse. This option is correct.
D. Saying "You should talk to your family about your feelings" is not a therapeutic response, as it implies that the client is responsible for resolving their family issues and may increase their guilt or anxiety. This option is incorrect.
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