Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
The client reports joint pain in the knee and wrist with a history of gout in the family. The elevated uric acid level (7.2 mg/dL) supports a diagnosis of gout, a condition caused by uric acid crystal deposition in the joints. The negative ANA and normal ESR make inflammatory autoimmune conditions like rheumatoid arthritis and systemic lupus erythematosus unlikely.
Actions to Take:
Instruct the client to avoid foods high in purines.
Purine-rich foods (e.g., red meat, shellfish, organ meats) contribute to increased uric acid production, exacerbating gout symptoms. Dietary modifications can help reduce flare-ups and long-term complications.
Instruct the client to apply topical analgesics.
Topical analgesics can provide localized pain relief and reduce discomfort in affected joints. They serve as an adjunct to systemic medications in managing acute symptoms.
Parameters to Monitor:
Uric acid levels.
Monitoring uric acid levels helps assess the effectiveness of dietary changes and medications in preventing flare-ups and reducing joint damage.
Joint deformities.
Chronic gout can lead to joint destruction and tophi formation, so assessing for deformities helps track disease progression and the need for further interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
A. Encourage prolonged dangling before ambulation.
Prolonged dangling is not necessary for this client, who is already ambulating independently. Extended dangling may increase the risk of orthostatic hypotension without providing significant benefits.
B. Administer an enema.
An enema is not the first-line intervention for postoperative constipation. The client has had a bowel movement, albeit small and painful, so increasing fluids and noninvasive measures like a sitz bath should be attempted first.
C. Encourage oral fluid intake.
Adequate hydration helps soften stool and prevent constipation, a common postoperative concern. The client’s fluid intake should be increased to support bowel function and improve urinary output.
D. Irrigate indwelling catheter with 500 mL of fluid.
The client has pink urine but is maintaining an adequate output of 100 mL/hr. Routine catheter irrigation is unnecessary unless there is evidence of obstruction, such as decreased urine flow or clot formation.
E. Assist the client with a sitz bath.
A sitz bath can provide comfort by promoting relaxation of perineal muscles, reducing pain during bowel movements, and improving circulation to the surgical site, which may aid healing.
Correct Answer is ["A","B","D","F","G","I"]
Explanation
Yellowing of the eyes (Jaundice) → Isoniazid and Rifampin can cause hepatotoxicity, leading to jaundice.
Blurred vision → Ethambutol can cause optic neuritis, leading to blurred vision and color blindness.
Dry eyes (Incorrect) → Not a common side effect of TB medications.
Gastrointestinal:
Abdominal pain → Isoniazid, Rifampin, and Pyrazinamide are hepatotoxic and can cause liver inflammation and gastric irritation.
Weight gain (Incorrect) → TB medications are more likely to cause weight loss rather than gain.
Hematologic:
Increased bruising & bleeding tendencies → Rifampin can cause thrombocytopenia, increasing the risk of bruising and bleeding.
Insomnia (Incorrect) → Not a serious adverse effect of TB medications.
Genitourinary:
Darkening of the urine → Rifampin causes orange-red discoloration of urine, sweat, and tears, which is a benign but expected effect.
Urinary frequency (Incorrect) → Not a known adverse effect of TB medications.
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