A nurse is planning care for a toddler who has epiglottitis.

Which of the following interventions should the nurse include?

The correct answer is choice C. Taking a hot shower in the morning can help decrease stiffness and improve joint mobility for people with rheumatoid arthritis. This is one of the self-management strategies that can reduce pain and disability.

Choice A is wrong because applying cold packs directly on the skin of the affected joints can cause vasoconstriction and increase inflammation.

Cold therapy should be used with caution and with a barrier between the skin and the ice pack.

Choice B is wrong because biological response modifiers are not used to prevent infection, but to reduce inflammation and slow down joint damage in rheumatoid arthritis.

These medications can actually increase the risk of infection by suppressing the immune system.

Choice D is wrong because clustering physical activities during the day can cause fatigue and joint stress for people with rheumatoid arthritis.

It is better to pace activities throughout the day and take frequent breaks to rest the joints.

Normal ranges for rheumatoid arthritis are based on the disease activity score (DAS), which measures the number of swollen and tender joints, the level of inflammation in the blood, and the patient’s global assessment of health. A DAS below 2.6 indicates remission, a DAS between 2.6 and 3.2 indicates low disease activity, a DAS between 3.2 and 5.1 indicates moderate disease activity, and a DAS above 5.1 indicates high disease activity.

The correct answer is c. Document the client's behavior prior to being placed in seclusion.

Rationale for Choice a. Discuss with the client his inappropriate behavior prior to seclusion:

While discussing the client's behavior may be helpful in some situations, it is not the most appropriate action to take immediately before seclusion. This is because:

1. Escalation:Attempting to discuss behavior in the moments leading up to seclusion can potentially escalate the situation and further jeopardize the safety of the client,staff,and other patients.
2. Impaired Insight:Clients requiring seclusion may have limited ability to engage in rational discussion due to heightened emotional states,cognitive impairment,or acute mental illness.
3. Limited Receptiveness:The client may not be receptive to feedback or discussion while in a state of crisis,potentially leading to frustration and further agitation.

Rationale for Choice b. Offer fluids every 2 hr.:

Offering fluids is a basic nursing intervention, but it is not the priority action in this scenario. The primary focus at this time is ensuring safety and managing the acute behavioral crisis. Addressing hydration needs can be attended to after the client is safely placed in seclusion.

Rationale for Choice d. Assess the client’s behavior once every hour.:

Regular assessment is crucial, but hourly assessment is not frequent enough in this situation. Clients in seclusion require close monitoring and assessment at more frequent intervals to ensure their safety and well-being, as well as to evaluate the effectiveness of the seclusion intervention.

Rationale for Choice c. Document the client’s behavior prior to being placed in seclusion.:

This is the most appropriate action for the nurse to take for the following reasons:

1. Legal and Ethical Requirements:Accurate documentation of the client's behavior prior to seclusion is essential for legal and ethical reasons.It serves as a record of the rationale for seclusion,supporting the decision-making process and ensuring adherence to best practices and patient rights.
2. Assessment and Intervention Planning:Detailed documentation provides valuable information for ongoing assessment and intervention planning.It allows healthcare professionals to track the client's progress,identify patterns in behavior,and make informed decisions about the continuation or discontinuation of seclusion.
3. Communication and Collaboration:Comprehensive documentation facilitates effective communication and collaboration among the healthcare team members,ensuring continuity of care and promoting a holistic approach to the client's treatment.
4. Evaluation and Quality Improvement:Accurate documentation enables evaluation of the effectiveness of seclusion interventions and contributes to quality improvement initiatives within the healthcare setting.