Exhibits

Data is evaluated to determine possible condition and appropriate interventions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Potential Condition:

• Rheumatoid arthritis (RA):
  • RA is a chronic autoimmune disorder that causes inflammation in the joints, leading to pain, stiffness, and swelling.
  • The patient has several classic signs of RA:
    • Pain and stiffness in bilateral hands and wrists: A hallmark of RA, particularly in the morning (worse upon waking).
    • Positive rheumatoid factor and positive antinuclear antibody: Both are commonly seen in RA.
    • Elevated erythrocyte sedimentation rate (ESR): This indicates inflammation, which is typical in RA.
    • X-ray findings of soft tissue swelling and marginal erosions: These are common in RA and suggest joint damage.

Actions to Take:

1. Educate on disease process and management:
   • It’s essential for the nurse to educate the patient on RA, its chronic nature, and the need for lifelong management. This will include medication adherence, managing flare-ups, and joint protection techniques.
2. Consult dietician for nutrition and weight loss:
   • Obesity can exacerbate RA symptoms due to increased joint stress. Encouraging weight loss can help reduce strain on affected joints and improve overall health. A dietician can help with weight management strategies and recommend anti-inflammatory foods.

Parameters to Monitor:

1. Pain:
   • Monitoring pain levels regularly is critical for assessing the effectiveness of treatment and making necessary adjustments to the pain management plan (e.g., the ibuprofen regimen).
2. Blood glucose:
   • Since the patient has a BMI of 31, there is an increased risk for type 2 diabetes mellitus, which is common in patients with RA. Additionally, if the patient is prescribed corticosteroids for RA management, monitoring blood glucose is crucial, as corticosteroids can elevate blood sugar levels

A. Discontinuing the infusion may lead to increased clotting and potential obstruction of the catheter. Continuous bladder irrigation is essential to keep the bladder clear of clots and debris following surgery.

B. Manually irrigating the catheter can help clear any clots that may be obstructing the catheter, ensuring adequate drainage and preventing complications such as bladder distention or retention. This is the most immediate and appropriate action to take in response to the presence of clots.

C. Monitoring catheter drainage is important; however, it does not address the potential issue of clots obstructing the flow of urine, which is the priority concern in this scenario.

D. Decreasing the flow rate may not be beneficial and could lead to inadequate irrigation of the bladder, which could exacerbate clot formation and urinary retention.