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 D
Explanation
A. Throbbing pain can be a common response after a fracture and cast application but does not necessarily indicate an emergency situation.
B. Circumferential edema could suggest complications, but it is not as immediately concerning as the vascular status of the limb.
C. An increased temperature in the lower extremity could indicate inflammation or infection, but it does not require immediate intervention compared to signs of impaired circulation.
D. A pale foot with sluggish capillary refill suggests compromised blood flow, which is a medical emergency requiring immediate assessment and intervention to prevent ischemia or compartment syndrome.
Correct Answer is B
Explanation
A. Removing ink marks can lead to difficulty in accurately targeting the radiation area, so the marks should be left in place until the treatment course is complete.
B. Protecting the skin from sunlight exposure is crucial, as the irradiated skin is more sensitive and at increased risk for sunburn. This recommendation helps to prevent further irritation and damage to the skin during and after treatment.
C. While moisturizing lotions can be beneficial for maintaining skin integrity, they should be used cautiously and only if prescribed by the healthcare provider, as some products may cause irritation.
D. The skin inside the radiation portal site should be washed gently with mild soap and water to keep it clean; avoiding washing is not advisable as it can lead to skin breakdown.
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