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.
The Correct Answer is []
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:
- 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.
- 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:
- 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).
- 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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Apply a nonrebreather oxygen mask. This will help increase the oxygen concentration delivered to the client's lungs and improve oxygen saturation.
B. Increase oxygen flow. Increasing the oxygen flow rate can help to further improve oxygen delivery.
C. Raise the head of the bed. This can help improve lung expansion and facilitate breathing.
D. Take and monitor vital signs. This will help assess the client's response to interventions and identify any deterioration.
E. Administer additional nebulizer treatment as prescribed. If the client's symptoms are not improving, additional nebulizer treatments may be necessary.
F. Provide client incentive spirometer and instruct on use: While incentive spirometry can be helpful in preventing atelectasis, it is not a priority in this acute situation where the client's immediate need is to improve oxygenation and reduce airway obstruction.
Correct Answer is A
Explanation
A. A headache that worsens upon sitting up is characteristic of a post-lumbar puncture headache, indicating a potential complication related to cerebrospinal fluid leakage.
B. Pain in the lower back after the procedure can be normal and does not necessarily indicate a complication.
C. Nausea and vomiting can occur but are not specific indicators of a complication following a lumbar puncture.
D. Sore throat when swallowing and talking is not typically associated with lumbar puncture complications and may relate to other causes such as anxiety or dehydration.
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